342700492-2-16-2021-27-AS-VBRN-BYAQLP-20210216111613

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700492
Report Date: 02/06/2021
Date Signed: 02/16/2021 11:16:33 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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 III		FACILITY NUMBER:	342700492
ADMINISTRATOR:	JULIE NONU		FACILITY TYPE:	740
ADDRESS:	573 SHAW RIVER WAY		TELEPHONE:	(916) 469-9145
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	6	CENSUS:	DATE:	02/06/2021
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Julie Nonu		TIME COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Victoria Brown contacted the facility via telephone to commence an unannounced Tele-visit on 2/6/2021 at 11:45am due to COVID-19 and pre-cautionary measures. LPA met with Julie Nonu, Administrator on record and discussed the purpose of the call and the elements of this type of visit. LPA obtained a Special Incident Report indicating on 7/3/20 at 9:30am resident #1 (R1) left the facility. At 7:00pm, R1 called the facility to inform staff #1 (S1) that R1 was going to Reno. The facility contacted the Administrator Ratu “Pio” Vunimatana and the placement agency. The resident was out of the facility for 9 ½ hours and Community Care Licensing (CCL) was not notified. LPA observed R1’s Physician Report that indicates R1 is ambulatory but not able to leave the facility unassisted, there is no indication that R1 has a diagnosis of Mild Cognitive Impairment or Dementia. LPA also observed that this report is not dated. LPA observed R1’s Appraisal/Needs and Services Plan dated 6/17/20 which indicated that R1 is confused and doesn’t follow directions at times and is using a wheelchair for mobility. It also indicates that when assessed R1 is very independent. This document was signed by R1 and the Administrator.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 III	FACILITY NUMBER: 342700492
	VISIT DATE: 02/06/2021

NARRATIVE

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Administrator Ratu “Pio” Vunimatana stated that the Sacramento Police Department arrived to investigate the absent without leave (AWOL) of this resident but did not take a report because the resident is in daily contact with the facility ensuring they are aware of R1’s well-being. The administrator indicated that a missing person report will be called into the Reno police department.

Administrator Ratu “Pio” Vunimatana also stated that R1 does not have a responsible party and is self-reliant. He stated that R1 is very alert, however, no medications were taken with R1 on this AWOL.

Based on the resident being missing from 7/3/20 at 9:30am through to the present day, the facility will be cited deficiencies during this visit.

The staff reported this information to Community Care Licensing on 7/10/20 in writing which is within 7 days. However, the licensee did not notify CCL within 24 hours as required by Title 22 regulations.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. Civil penalties shall be assessed when the licensee fails to correct the violation to Health and Safety Code Section 1569.605 following any appropriate extensions to the plan of correction due date. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted with Julie Nonu via telephone and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2021

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 III	FACILITY NUMBER: 342700492
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/06/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/08/2021 Section Cited	1 2 3 4 5 6 7	Observation of the Resident The licensee shall ensure that residents are regularly observed…and that appropriate assistance is provided. This requirement is not met as evidenced by: facility documentation, interviews and records review, the resident was absent without leave (AWOL) for 18 days. The Licensee failed to adequately supervise R1 which allowed for R1’s elopement from the facility. This possess an immediate health and safety risk to residents in care.
Type A 02/08/2021 Section Cited	1 2 3 4 5 6 7	Reporting Requirements Occurrences…which threaten the welfare, safety or health of residents, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement is not met as evidenced by: The Licensee failed to notify CCL of R1’s elopement from the facility in a timely manner. This possess an immediate health and safety risk to residents in care.
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2021

LIC809 (FAS) - (06/04)

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