347003297-8-15-2023-59-AS-MSEY-CUWMRR-20230821095043

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347003297
Report Date: 08/15/2023
Date Signed: 08/15/2023 03:26:40 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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
08/09/2023 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 59-AS-20230809142424

FACILITY NAME:	LA SERENA HOUSE		FACILITY NUMBER:	347003297
ADMINISTRATOR:	VILLAROSA, MARIBEL		FACILITY TYPE:	740
ADDRESS:	8970 LA SERENA DRIVE		TELEPHONE:	(916) 966-0865
CITY:	FAIR OAKS	STATE: CA	ZIP CODE:	95628
CAPACITY:	6	CENSUS: 6	DATE:	08/15/2023
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Aida Briones, Licensee		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Staff did not prevent inappropriate interactions between residents in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Licensee, Aida Briones, to conduct a complaint investigation into the allegation listed above.

During today's visit, LPA conducted interviews regarding the allegation.

The results of the investigation are as follows:

Allegation: Staff did not prevent inappropriate interactions between residents in care

** Report continued on 9099-C **

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

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 59-AS-20230809142424

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LA SERENA HOUSE	FACILITY NUMBER: 347003297
	VISIT DATE: 08/15/2023

NARRATIVE

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Interview with resident R1 indicated that there has been conflict between them and resident R2 at the facility, including R2 using offensive hand gestures towards R1 and R2 blocking the path of R1 in shared spaces of the facility. Interview with R2 indicated that the alleged conflict is a misunderstanding and that they have been working to avoid conflict with R1 by keeping their distance from R1. Interview with R2 indicated that they feel the facility is taking action to resolve the situation between R1 and R2.

Interviews with staff members S1 and S2, as well as Licensee, indicated that they are currently separating residents R1 and R2 to de-escalate their conflict. Interviews indicated that decision to separate R1 and R2 was decided by Licensee and relevant party. Interviews with staff and Licensee indicated that no physical altercations have taken place at the facility.

Interview with relevant party indicated that they have no concerns regarding the facility and they are happy with the actions taken by the facility. Relevant party indicated that the facility goes above and beyond with caring for R1.

All interviews conducted did not indicate any instances of physical altercations between R1 and R2. Interview with R2 indicated an incident in which a resident became physical with a caregiver 3 years ago, but R2 stated that the facility was active in resolving the situation and no other physical altercations have taken place at the facility.

Based on interviews conducted, the preponderance of evidence standards have not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation 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.

Exit interview was conducted with Licensee. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

LIC9099 (FAS) - (06/04)

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