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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 365530010
Report Date: 12/28/2022
Date Signed: 12/28/2022 11:56:12 AM

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
12/22/2022 and conducted by Evaluator Bernadette Allen
COMPLAINT CONTROL NUMBER: 56-AS-20221222162012
FACILITY NAME:SAN BERNARDINO SERENITY LIVINGFACILITY NUMBER:
365530010
ADMINISTRATOR:MAGTOTO, EDWARDFACILITY TYPE:
735
ADDRESS:2414 OGDEN ST.TELEPHONE:
(213) 618-0938
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92407
CAPACITY:20CENSUS: 17DATE:
12/28/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Edward MagtotoTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Facility staff did not keep the facility free of insects
Facility staff does not keep the facility clean and sanitary
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Bernadette Allen made an unannounced visit to the facility for the purpose of initiating and delivering findings on the complaints above. LPA met with Edward Magtoto Administrator who was informed of the purpose of my visit and the allegations above.

Allegation 1: Facility has bed bugs.
Allegation 2: Facility staff does not keep the facility clean and sanitary

LPA interviewed staff (S1, S2, S3, S4), all indicated the facility did have bed bugs. The administrator provided a contract for the service pest control treatment which was done on 12/15/2022. LPA obtained a statement from the pest control company detailing the service that was conducted on 7/20/2022 and 12/15/2022 which was for pest and bed bugs. LPA toured the facility bedrooms and interviewed ten (10) residents who said there were bed bugs about 2-3 weeks ago and the pest control company has been out to spray. During the visit LPA Allen observed there were small dots of dry blood on client 1 (C1) mattress pad and client 2 (C2) had small bites on their arms and legs. LPA did not see any bed bugs in C1 or C2 pesonal items during the visit. During the visit the facility was clean and sanitary.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
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 2
Control Number 56-AS-20221222162012
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: SAN BERNARDINO SERENITY LIVING
FACILITY NUMBER: 365530010
VISIT DATE: 12/28/2022
NARRATIVE
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Based on interviews with staff and clients, record review, and tour of the facility the allegations were deemed to be UNSUBSTANTIATED.

A finding of UNSUBSTANTIATED means that 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.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2