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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880775
Report Date: 07/22/2024
Date Signed: 07/22/2024 01:23:01 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/12/2024 and conducted by Evaluator Magda Malcore
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240712094958
FACILITY NAME:SERENITY ADULT CARE HOMES IVFACILITY NUMBER:
361880775
ADMINISTRATOR:BOYCE, DARLEENEFACILITY TYPE:
735
ADDRESS:11542 AUTUMN STREETTELEPHONE:
(760) 523-1108
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY:4CENSUS: 3DATE:
07/22/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Julia Broadway - House ManagerTIME COMPLETED:
01:25 PM
ALLEGATION(S):
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Staff made an inappropriate comment towards a client
Staff isolated a client while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a complaint investigation on the above allegations. LPA met with Julia Broadway, House Manager, who was informed of today’s visit.

Regarding the allegation, staff made an inappropriate comment towards a client, three (3) clients interviewed deny staff have made an inappropriate comment towards them. Three (3) staff interviewed deny making an inappropriate comment towards a client.

Regarding the allegation, staff isolated a client while in care, three (3) clients interviewed deny staff have isolated them while in care. Three (3) staff interviewed deny isolating a client while in care.

Based on record review and interviews, the allegations are Unsubstantiated. A finding of Unsubstantiated means that although the allegation may have happened or is valid,
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024
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-20240712094958
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SERENITY ADULT CARE HOMES IV
FACILITY NUMBER: 361880775
VISIT DATE: 07/22/2024
NARRATIVE
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there is not a preponderance of evidence to prove the alleged violation did or did not occur.
An exit interview was conducted with the House Manager and a copy of this report with Appeal Rights was provided to the House Manager at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2