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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880775
Report Date: 09/07/2023
Date Signed: 09/07/2023 02:15:26 PM

Unsubstantiated


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
06/01/2023 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230601080814
FACILITY NAME:SERENITY ADULT CARE HOMES IVFACILITY NUMBER:
361880775
ADMINISTRATOR:BOYCE, DARLEENEFACILITY TYPE:
735
ADDRESS:11542 AUTUMN STREETTELEPHONE:
(714) 225-2482
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY:4CENSUS: 2DATE:
09/07/2023
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Julia Broadway, house managerTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Staff refused to take resident for a medical assessment.
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 house manager Julia Broadway and explained the purpose of the visit. The investigation included file reviews and interviews with relevant parties.

The allegation alleged that staff #1 (S1) refused to take resident #1 (R1) to their medical assessment. LPA Nickolas 'interview with the administrator revealed that they denied this allegation. LPA Nickolas' interview with the S1 revealed that they denied this allegation. LPA Nickolas attempted to interview R1 on June 1, 2023, during the initial 10-day. However, R1 was hospitalized. During today's visit, LPA Nickolas discovered that R1 no longer resides at the facility. LPA Nickolas interviewed resident #2 (R2) and resident #3 (R3), and they denied this allegation. LPA Nickolas' facility file review revealed that the facility has reported any unusal injury/incident requiring medical assessments or treatments assosiated with R1 according to regulatory time frames and has proof of medical discharge paperwork.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023
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 2
Control Number 56-AS-20230601080814
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 IV
FACILITY NUMBER: 361880775
VISIT DATE: 09/07/2023
NARRATIVE
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The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

A finding of Unsubstantiated means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted and copy of this report was provided.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2