<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700828
Report Date: 03/24/2022
Date Signed: 03/24/2022 03:56:44 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
01/10/2022 and conducted by Evaluator Victoria Brown
COMPLAINT CONTROL NUMBER: 27-AS-20220110133721
FACILITY NAME:LOVE AND SERENITY OF ELK GROVE IIIFACILITY NUMBER:
342700828
ADMINISTRATOR:CASTRO, BIANCAFACILITY TYPE:
740
ADDRESS:9442 MAZATLAN WAYTELEPHONE:
(916) 585-5483
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 6DATE:
03/24/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Lusiana BulameicavaiTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Documents not provided to POA upon request
Staff did not notify POA of resident's need for medication refill
Staff do not give resident medication timely
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Liecensing Program Analysts (LPA) victoria Brown arrived unannounced on 3/24/22 at 1:00pm to conclude the complaint investigation. LPA met with Lusiana Bulameicavai, Caregiver and stated the purpose of the visit.

Regarding allegation, "Documents not provided to POA upon request," the investigation revealed that documents requested by Resident #1's (R1) Responsible Party (RP) such as shower schedule and medication list was not provided upon request or thereafter.

Regarding allegation, "Staff did not notify POA of resident's need for medication refill" the investigation revealed that staff stated to R1 that medication had run out instead of informing the Responsible party which was the normal protocol.

Substantiated
Estimated Days of Completion: 60
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022
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-20220110133721
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 OF ELK GROVE III
FACILITY NUMBER: 342700828
VISIT DATE: 03/24/2022
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
26
27
28
29
30
31
32
Regarding allegation, "Staff do not give resident medication timely" the investigation revealed that R1's medication was deemed to be depleted and needing a refill and/or a new prescription. S1 stated that it had already been refilled and was placed in the back of the medication cabinet, overlooked by S1. Due to this oversight, R1 missed the medication for 1 day while waiting for it to be refilled. A review of the medication log from the Pharmacy the medication was refilled on 12/17/21.

Based on interviews, and documentation the preponderance of evidence standards has been met; therefore, the above allegation(s) are found to be SUBSTANTIATED.

A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 9099D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Caregiver was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, a copy of the report was given.






SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20220110133721
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 OF ELK GROVE III
FACILITY NUMBER: 342700828
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2022
Section Cited
CCR
87506(c)(1)
1
2
3
4
5
6
7
Resident Records
All information and records obtained from or regarding residents...licensee and all employees shall reveal or make available confidential information...or that of his designated representative.
1
2
3
4
5
6
7
Administrator shall submit a statement that all regulations will be followed regarding resident records. The POC shall be faxed by POC due date.
8
9
10
11
12
13
14
This regulation was not met as evidence by: The licensee did not provide requested documents to responsible party. Based on interviews the resident records were not provided as requested to the RP.
This poses a potential risk to residents in care.
8
9
10
11
12
13
14
Type B
03/29/2022
Section Cited
CCR
87464(f)(4)
1
2
3
4
5
6
7
Basic Services

Basic services shall at a minimum include
Personal assistance and care as needed by the resident...assistance with taking prescribed medications...
1
2
3
4
5
6
7
Administrator shall conduct an in-service with staff regarding medication protocols. Completion to be faxed by POC due date.
8
9
10
11
12
13
14
This regulation was not met as evidence by: Licensee did not assist R1 with medication for 1 day. Based on interviews the medication was missed.
This poses a potential risk to residents in care.
8
9
10
11
12
13
14
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 RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
01/10/2022 and conducted by Evaluator Victoria Brown
COMPLAINT CONTROL NUMBER: 27-AS-20220110133721

FACILITY NAME:LOVE AND SERENITY OF ELK GROVE IIIFACILITY NUMBER:
342700828
ADMINISTRATOR:CASTRO, BIANCAFACILITY TYPE:
740
ADDRESS:9442 MAZATLAN WAYTELEPHONE:
(916) 585-5483
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 6DATE:
03/24/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Lusiana BulameicavaiTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not safeguard resident's personal property
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Liecensing Program Analysts (LPA) victoria Brown arrived unannounced on 3/24/22 at 1:00pm to conclude the complaint investigation. LPA met with Lusiana Bulameicavai, Caregiver and stated the purpose of the visit.
Regarding allegation, "Staff do not safeguard resident's personal property" the investigation revealed that during interviews all concur that Resident #1 (R1) instructed staff to run the car to ensure the battery does not go dead on a regular basis. Due to the fact that Staff #3 (S3) is unable to be interviewed and R1 has deceased the allegation is deemed to be Unsubstantiated as to whether S3 had actually driven the car without permission from R1 and/or the Responsible Party (RP). Based on lack of evidence and interviews,there appears to be no negligence on behalf of the staff.
The preponderance of evidence standards has not been met; therefore, the above allegation(s) is found to be UNSUBSTANTIATED. A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was conducted, and a copy of this report was provided.
Unsubstantiated
Estimated Days of Completion: 60
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20220110133721
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 OF ELK GROVE III
FACILITY NUMBER: 342700828
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2022
Section Cited
CCR
87465(a)(4)
1
2
3
4
5
6
7
Incidental Medical and Dental Care
A plan for incidental medical and dental care shall be developed by each facility...licensee shall assist residents with self-administered medications as needed.
1
2
3
4
5
6
7
Administrator shall conduct a medication management in-service with staff and submit complettion by fax by POC due date.
8
9
10
11
12
13
14
This regulation was not met as evidence by: The licensee did not notify R1's Responsible party medication was depleted. Based on Interviews and medication documentation the refill was processed and overlooked by staff resulting in missed medication.
This poses a potential risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5