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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800059
Report Date: 11/21/2022
Date Signed: 01/12/2023 10:31:17 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/17/2022 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220817141425
FACILITY NAME:SERENITY ADULT CARE HOMES IIFACILITY NUMBER:
361800059
ADMINISTRATOR:BOYCE, DARLEENEFACILITY TYPE:
735
ADDRESS:14534 HANDSDALE STREETTELEPHONE:
(714) 225-2482
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY:6CENSUS: 3DATE:
11/21/2022
UNANNOUNCEDTIME BEGAN:
11:42 AM
MET WITH:Pebbles Nakielski, Administrator
TIME COMPLETED:
12:52 PM
ALLEGATION(S):
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Staff interfered with visitations to a client
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rayshaun Nickolas made an unannounced visit to the facility to deliver the finding on the above allegation. LPA met with Administrator Pebbles Nakielski and explained the purpose of the visit. The investigation consisted of file reviews and interviews with relevant parties.

The allegation alleges that on June 10, 2022, the reporting party (RP) was contacted by staff # 1 (S1) and informed that the facility is under a quarantine due to an outbreak. The RP further states they were kept away from their family member for four (4) weeks due to the outbreak in the facility. An interview with the Licensee revealed that the family was never told they could not visit client #1 (C1). The Licensee also states the family wanted to refrain from complying with providing proof of vaccination status or proof of COVID-19 tests 48 hours before the visit per the California Department of Social Services (CDSS) policy. The Licensee further states that C1 family members were offered Facetime video calls with C1 as a form of visitation when C1 was quarantined during the outbreak in the facility. The Licensee's visitation policy violates CDSS, Provider Information Notices 22-07-ASC (Pin 22-07-ASC) dated February 7, 2022.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022
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 56-AS-20220817141425
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: SERENITY ADULT CARE HOMES II
FACILITY NUMBER: 361800059
VISIT DATE: 11/21/2022
NARRATIVE
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Based on the evidence gathered during the investigation, the above allegation is Substantiated. A finding that the complaint is Substantiated means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

An exit interview was conduct were a copy of this report (LIC 9099), LIC 9099D, and appeal rights were discussed and provide.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022
LIC9099 (FAS) - (06/04)
Page: 5 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/17/2022 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220817141425

FACILITY NAME:SERENITY ADULT CARE HOMES IIFACILITY NUMBER:
361800059
ADMINISTRATOR:BOYCE, DARLEENEFACILITY TYPE:
735
ADDRESS:14534 HANDSDALE STREETTELEPHONE:
(714) 225-2482
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY:6CENSUS: 3DATE:
11/21/2022
UNANNOUNCEDTIME BEGAN:
11:42 AM
MET WITH:Pebbles Nakielski, AdministratorTIME COMPLETED:
12:52 PM
ALLEGATION(S):
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Client sustained multiple unexplained injuries while in care
Client is not consuming an appropriate amount of fluids while in care
Client dietary needs are not being addressed while in care
INVESTIGATION FINDINGS:
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 Licensing Program Analyst (LPA) Rayshaun Nickolas made an unannounced visit to the facility to deliver the finding on the above allegation. LPA met with Administrator Pebbles Nakielski and explained the purpose of the visit. The investigation comprised LPA observations, file reviews, photograph reviews, and interviews with relevant parties.

Allegation #1 “Client sustained multiple unexplained injuries while in care”. The allegation alleges that on July 9, 2022, the reporting party (RP) stated that while visiting client # 1 (C1), they observed four (4) distinct yellow bruises running down C1’s right forearm. The RP further that on July 14, 2022, they questioned staff # 1 (S1) about the yellow bruises found on C1’s forearm and was advised that C1 had blood work on July 7, 2022. Interviews with a witness revealed finding no bruises on C1’s forearm. Investigation into this incident reveals insufficient evidence to corroborate the allegation.

Allegation #2 “Client is not consuming an appropriate amount of fluids while in care”. The allegation alleges that on four (4) occasions, the RP visited C1 and did not see SI with a single beverage near them at any time.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 56-AS-20220817141425
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: SERENITY ADULT CARE HOMES II
FACILITY NUMBER: 361800059
VISIT DATE: 11/21/2022
NARRATIVE
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The RP further inquired with the facility staff about always providing C1 with water in their room, and the facility staff stated, “C1 is allowed drinks at breakfast, lunch, and dinner”. LPA observed a five (5) gallon water bottle with a dispenser located in the facility's kitchen, easily accessible to residents in care. LPA interview with a witness revealed that during an unannounced visit to the facility, they saw C1 consume a couple of glasses of lemonade. Investigation into this incident reveals insufficient evidence to corroborate the allegation.

Allegation #3 “Client dietary needs are not being addressed while in care”. The allegation alleges that C1 has lost a substantial amount of weight during their stay at the facility between May 27, 2022 and August 4, 2022. LPA interview with a witness revealed that during two (2) visits to the facility, the witness saw C1 served and consumed a well-balanced meal. LPA observed that the facility's food supplies were labeled with purchase dates and adequately stored. The facility had more than a seven (7) day supply of non-perishable foods and a two (2) day supply of perishable food. LPA observed that the facility's fresh fruits and vegetables were in good condition. LPA observed plenty of fresh fruits and vegetables at the facility. LPA also observed a weekly food menu located in the facility's kitchen. Investigation into this incident reveals insufficient evidence to corroborate the allegation.

Based on the investigation, the above findings are Unsubstantiated. A finding of unsubstantiated means although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 56-AS-20220817141425
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: SERENITY ADULT CARE HOMES II
FACILITY NUMBER: 361800059
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/21/2022
Section Cited
CCR
85072(b)(4)
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85072(b)(4) Personal Rights
(4) To have visitors, including advocacy representatives, visit privately during waking hours, provided that such visitations do not infringe upon the rights of other clients.

This requirement was not met as evidenced by:
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Licensee shall read CDSS PIN 22-07-ASC and any CDSS PINs that update the visitation policies from the issuance of PIN 22-07-ASC. Licensee shall update their visitation policies to incorporate any new CDSS policies as outline in the PINs.
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Based on interviews, the licensee did not ensure to that R1 was able to visit with their family as outlined in PIN-22-07-ASC, which poses a potential health, safety, personal rights risks to persons in care.
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DEF CONT'D: Licensee shall submit the facility's updated visitation policies to the Regional Office (RO) by 12/12/2022.
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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.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5