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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700491
Report Date: 10/15/2026
Date Signed: 10/15/2026 04:52:21 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/20/2026 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20260120093748
FACILITY NAME:LOVE AND SERENITY IIFACILITY NUMBER:
342700491
ADMINISTRATOR:WAQALALA, UNAISIFACILITY TYPE:
740
ADDRESS:5942 PARK VILLAGE STTELEPHONE:
(916) 476-5595
CITY:SACRAMENTOSTATE: CAZIP CODE:
95822
CAPACITY:6CENSUS: 6DATE:
10/15/2026
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Christina AllenTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Neglect/Lack of Supervision: Staff sleep at the facility while on shift.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Kevin Gould and Mabel Cummings made an unannounced inspection to Love and Serenity II RCFE on 10/15/26 at 10/15/26 to conclude the investigation of the above allegation and to deliver the findings. LPA Gould met with staff Christina Allen and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegation is substantiated. LPA conducted file review and observed R1's pre-placement appraisal completed by facility administrator stating R1 needed overnight observation/supervision. LPA reviewed the most recent staff schedule and observed the facility is currently operating with one primary live in caregiver, S1 who is scheduled from Monday through Friday 7am to 7pm. LPA conducted interviews with two staff members who confirmed that there is no awake staff on duty during overnight shift.

Report continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 27-AS-20260120093748
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LOVE AND SERENITY II
FACILITY NUMBER: 342700491
VISIT DATE: 10/15/2026
NARRATIVE
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Furthermore, LPA observed a written incident report for R2 which was not submitted to the department that documented R2 leaving the facility unassisted at 2am which was reported to staff at approximately 7am by another resident. LPA also received statements from R3 that they have had to alert staff members sleeping that a resident has fallen during overnight shifts.

The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of neglect/lack of supervision is substantiated.

The following deficiency is cited per California Code of Regulations, TITLE 22. Due to the facility having a second violation within 12 months, an immediate civil penalty is issued during today's inspection.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home.
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/20/2026 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20260120093748

FACILITY NAME:LOVE AND SERENITY IIFACILITY NUMBER:
342700491
ADMINISTRATOR:WAQALALA, UNAISIFACILITY TYPE:
740
ADDRESS:5942 PARK VILLAGE STTELEPHONE:
(916) 476-5595
CITY:SACRAMENTOSTATE:CAZIP CODE:
95822
CAPACITY:6CENSUS: 6DATE:
10/15/2026
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Christina AllenTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Neglect/Lack of Supervision: Staff did not provide adequate care and supervision resulting in resident being injured.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Kevin Gould and Mabel Cummings made an unannounced inspection to Love and Serenity II RCFE on 10/15/26 at 10/15/26 to conclude the investigation of the above allegation and to deliver the findings. LPA Gould met with staff Christina Allen and together discussed the investigation details.

Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA Gould was unable to corroborate the allegations. LPA conducted interviews with two staff members, two residents, Reporting Party (RP) and attempted to interview A1 and R1. LPA also conducted file review and reviewed R1's file and medical records. LPA noted approximately five documented falls where R1 was evaluated at the hospital. The staff member present during R1's time at the facility was no longer working at the facility by the time the department received the complaint and that staff member could not be interviewed to confirm information regarding falls and possible injuries.
Report Continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20260120093748
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LOVE AND SERENITY II
FACILITY NUMBER: 342700491
VISIT DATE: 10/15/2026
NARRATIVE
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LPA could not determine the time and manor of the falls incurred by R1. LPA could identify the time, location and circumstances of any of the reported or documented falls to determine if there was appropriate care being provided to prevent falls. LPA conducted an interview with R1's former roommate, R2, who confirmed R1 had one fall where she slid off the edge of the edge of their bed but could not verify if R1 received any injuries. R2 confirmed interventions were made by the facility to prevent R1 from falling or preventing injuries from falls. R1 reported to LPA that the facility had a bed rail installed for R1 and installed a fall mat along R1's bed to prevent R1 from falling and injuring self.

Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of (indicate the complaint allegation) are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies is cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Citations on this Visit Report are Under Appeal!

Control Number 27-AS-20260120093748
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LOVE AND SERENITY II
FACILITY NUMBER: 342700491
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
10/16/2026
Section Cited
CCR
87464(f)(1)
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 Basic Services: Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidence by interviews and file reviews, the Licensee did not ensure
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Facility has agreed to having an overnight staff member awake and working. Facility will provide the department with an updated staff schedule (LIC-500) with all staff scheduled times and days they are working including an overnight shift with an awake staff member to meet the needs of residents in care.
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resident supervision was adequate to meet needs during the night shift as R1's appraisal indicated . This posed an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5