342700492-2-2-2022-27-AS-KHOS-CCDJYP-20220310062817

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700492
Report Date: 02/02/2022
Date Signed: 02/02/2022 02:59:00 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
01/24/2022 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20220124113827

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: 3	DATE:	02/02/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Talica Wilikiligi		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility does not meet resident's nutritional needs
Facility does not assist resident with self administered medications
Facility not maintained clean and sanitary

INVESTIGATION FINDINGS:

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Licensing Program Analyst Victoria Brown arrived at 9:30am on 2/2/22 to investigate the above mentioned allegations. LPA was met by Talica Wilikiligi, Caregiver and stated the purpose of the visit. LPA toured the room of the former resident #1 (R1), and observed the food that is presently in the facility. LPA interviewed staff #1 (S1-S3) and R1 during this visit. LPA was made aware today by S1, that R1 moved out of the facility on 2/1/22. LPA observed the Physician Report dated 1/9/21, the discharge documents and Medication Records of R1. LPA interviewed the Administrator of facility R1 relocated to as well.

In regards to the allegation, "Facility does not meet resident's nutritional needs", LPA was made aware by R1 that cooked food from certain staff was favored. LPA did not observe documentation that R1 was prescribed a low sodium diet by a licensed skilled professional. LPA did however, observe a special diet noted of "NAS diabetic" which means non-caloric artifical sweetners. There was confirmation from interviews that R1 did have a low intake of sugary items in the home and did not need to seek medical attention for diabteic purposes or a medication change regarding nutrition.

Unfounded

Estimated Days of Completion: 30

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022

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

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20220124113827

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 III	FACILITY NUMBER: 342700492
	VISIT DATE: 02/02/2022

NARRATIVE

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In regards to the allegation, "Facility does not assist resident with self administered medications", LPA observed during the investigation that R1 had not run out of "Norco" used for pain. Upon relocation, R1 still had medication on hand. In addition, R1's medication was on auto refill with the pharmacy.

In regards to the allegation, "Facility not maintained clean and sanitary", LPA obtained information that the end table in R1's room was dirty and was eventually cleaned. LPA was made aware by R1 that certain staff was allowed to clean the room. LPA observed that there was an end table next to the bed with a small lamp on it and one near the closet with a tv on it. LPA did not observe dust or dirt on either during this visit.

The investigation revealed that the facility remain in compliance with the Title 22 regulations. The preponderance of evidence standards has not been met.

“This agency has investigated the complaint alleging, the above-mentioned allegation(s). We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.”

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were cited during this visit. An exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022

LIC9099 (FAS) - (06/04)

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