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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700491
Report Date: 09/24/2021
Date Signed: 09/24/2021 03:51:54 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/19/2021 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20210819122759
FACILITY NAME:LOVE AND SERENITY IIFACILITY NUMBER:
342700491
ADMINISTRATOR:RATU P VUNIMATANAFACILITY TYPE:
740
ADDRESS:5942 PARK VILLAGE STTELEPHONE:
(916) 476-5595
CITY:SACRAMENTOSTATE: CAZIP CODE:
95822
CAPACITY:6CENSUS: 4DATE:
09/24/2021
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Administrator, Anthony CamachoTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff not supervising resident resulting in multiple falls and injuries
Residents bed alarm was not in on position and unplugged by staff
Facility failed to report injury
INVESTIGATION FINDINGS:
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On 09/24/2021 at 3:00 PM, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit at this facility to deliver a complaint findings. Upon LPAs arrival, caregiver Elisha Dau was present at facility and contacted Administrator, Anthony Camacho who arrived a bit later. LPA met with Administrator Anthony Camacho and explained the purpose of the visit.

Throughout the course of the investigation, LPA conducted interviews and reviewed records. The investigation revealed that resident (R4) has fallen multiple time resulting in bruising on the legs. R4 also sustained a bump on the forehead due to a fall. The facility was informed by hospice agency (Dignity Health Hospice) to report R4’s falls; however, the facility did not report to R4’s agency as required. In addition, Dignity Health Hospice had provided R4 with bed alarms. The alarm will sound off when R4 attempts to get out of bed. It was observed by hospice nurse on 8/18/2021 that R4’s alarm was on the ground and disengaged. On 8/27/2021, during an inspection, LPA Truong observed the battery was unplugged from the alarm. Furthermore, the facility failed report injuries to Dignity Health Hospice and Licensing as required.

Report continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
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 4
Control Number 27-AS-20210819122759
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: LOVE AND SERENITY II
FACILITY NUMBER: 342700491
VISIT DATE: 09/24/2021
NARRATIVE
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As a result of this investigation, the Department finds the allegations above to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6 and/or Health and Safety Code.

Exit interview was conducted with Administrator Anthony Camacho, a copy of the report, LIC 9099-D and appeal rights were provided.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20210819122759
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: LOVE AND SERENITY II
FACILITY NUMBER: 342700491
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/27/2021
Section Cited
CCR
87411(c)
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Personnel Requirements – General. Responsibility for Providing Care and Supervision: The licensee shall provide care and supervision as necessary to meet the client's needs.

The requirement is not met as evidenced by:
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The Licensee shall sign up for training through CCL approved vendor list on the care and supervision responsibilities. The Licensee shall send CCL proof of registration for training for all staff by COB 9/27/2021. Upon completion of the training the facility will send to LPA proof of completion, list of staff attendees with their signatures with an acknowledgment of understanding and compliance with this regulation.
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Based on interviews and records reviewed, the Licensee did not provide adequate supervision to resident. Resident (R4) has sustained injuries from multiple falls due to bed alarms were not engaged. This poses an imminent health and safety risk to the residents in care.
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Type A
09/27/2021
Section Cited
CCR
87633(d)
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Hospice Care of Terminally Ill Residents. The licensee shall ensure that the hospice care plan is current, accurately matches the services actually being provided, and that the client’s care needs are being met at all times.

This requirement is not met as evidenced by:
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Licensee/Administrator shall ensure hospice care plan are follow at all time. Provide CCL with a written declaration stating that he/she has read and understands the Title 22 Regulations by 9/27/2021.
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Based on interviews and records reviewed, the facility did not follow the hospice care plan which require R4 to have bed alarm on. Resident R4 alarms was not on as required. This poses 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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20210819122759
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: LOVE AND SERENITY II
FACILITY NUMBER: 342700491
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/27/2021
Section Cited
CCR
87211(a)(2)
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Reporting Requirements:
Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following . . . Any incident which threatens the welfare, safety or health of any resident . . .

This requirement is not met as evidenced by:
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Administrator agrees to take training including but not limited to the following: Title 22 regulations, effective communication and record keeping and documentation. Training topics and dates shall be submitted by POC date, 09/27/2021.
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Based on interviews and records reviewed, the Licensee/Administrator did not report the incident to the Community Care Licensing Division (CCLD) as required by Title 22. Resident R4 had multiples falls resulting in injuries that was not reported to Licensing and hospice agency. This poses an imminent health and safety risk to the 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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4