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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366423573
Report Date: 07/27/2023
Date Signed: 07/27/2023 01:52:17 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
04/26/2022 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220426100253
FACILITY NAME:KAISER SPECIALIZED RESIDENTIAL SERRANOFACILITY NUMBER:
366423573
ADMINISTRATOR:REBA JORDANFACILITY TYPE:
735
ADDRESS:16146 SERRANO AVETELEPHONE:
(760) 242-5759
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY:4CENSUS: 4DATE:
07/27/2023
ANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:House Manager/Administrator Elizabeth GonzalezTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff are not following resident's care plan.
Staff did not respond to resident's request for care services in a timely manner.
Staff verbally abuse residents in care.
Facility does not have sufficient food for residents in care.
Residents are not receiving medications on a timely basis.
Facility staff are not following reporting requirements.
Facility falsifies residents' records.
Staff are not adequately supervising residents.
Facility staff sleep while on the job.
Facility staff refuse to give some residents food.
INVESTIGATION FINDINGS:
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On 07/27/2023 at 01:10 PM, Licensing Program Analyst (LPA) Melody Brown met with House Manager/Administrator Elizabeth Gonzalez at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office to deliver the findings of the above allegations. LPA Brown explained the purpose of the requested Office Visit. The investigation consisted of observation, interviews and a review of pertinent documentation.

The investigation was conducted by LPA Melody Brown. The investigation consisted of records review and interviews with relevant parties. The first allegation indicates that Staff are not following resident's care plan.During the investigation, LPA Brown did not find evidence to corroborate the allegation. Records review and interviews with staffs indicated that staffs are following residents/clients care plan at the facility. Staffs' interviews revealed that they are all informed and trained of their clients Care Plan, and their Management are making sure that they are doing what they've learned from their training. **Continuation in LIC9099C **
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
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 5
Control Number 56-AS-20220426100253
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: KAISER SPECIALIZED RESIDENTIAL SERRANO
FACILITY NUMBER: 366423573
VISIT DATE: 07/27/2023
NARRATIVE
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Clients’ interviews indicated that staffs are following what their doctor instructed them to do and LPA Brown unable to obtain information from two (2) residents/clients as they were unable to answer LPA Brown's questions. During the visit on 07/21/2023, LPA Brown reviewed clients’ documents and observed that staff are following clients Care Plan.

The second allegation indicates that Staff did not respond to resident's request for care services in a timely manner. Interviews with residents/clients indicated that staffs immediately respond to residents/clients request for care services. Residents/Clients interviews revealed that all staffs at the facility assist them right away every time they needed help. LPA Brown unable to obtain information from two (2) residents/clients as they were unable to answer LPA Brown's questions. Staffs' interviews indicated that they all respond to residents'/clients' request for care services in a timely manner and there's no incident that happened at the facility that their resident/client had to wait for their assistance because they always go to their resident/client immediately the soonest they were made aware of their resident/client request for care services or any assistance. During the visit on 07/21/2023, LPA Brown observed staffs responding right away to clients' request for assistance and LPA Brown observed that clients were helped in a timely manner.

The third allegation indicates that Staff verbally abuse residents in care. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with residents/clients indicated that all staffs at the facility are nice, respectful and kind and they denied any incident of a staff being verbally abusive to them. LPA Brown unable to obtain information from two (2) residents/clients as they were unable to answer LPA Brown's questions. Staffs’ interviews indicated that no staff at the facility verbally abused residents/clients in care and staff interviews revealed that no incident happened at the facility that staff verbally abused residents/clients in care.

The fourth allegation indicates that Facility does not have sufficient food for residents in care. Interviews with residents/clients indicated that that facility always have sufficient supply of food and they always have a lot of food to eat at the facility. LPA Brown unable to obtain information from two (2) clients as they were unable to answer LPA Brown's questions. Staffs' interviews revealed that they always have sufficient supply of food, and no incident happened that the facility does not have sufficient food for residents/clients in care. During the visit on 07/21/2023, LPA Brown toured the facility with House Manager/Administrator Elizabeth Gonzalez and LPA Brown observed that the facility has sufficient food for residents/clients with more than seven (7) *** Continuation in LIC9099C ***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 56-AS-20220426100253
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: KAISER SPECIALIZED RESIDENTIAL SERRANO
FACILITY NUMBER: 366423573
VISIT DATE: 07/27/2023
NARRATIVE
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days’ supply of non-perishable foods and more than two (2) days’ supply of perishable foods.

The fifth allegation indicates Residents are not receiving medications on a timely basis. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with residents/clients indicated that they are receiving their medication on time everyday and there's no incident that staffs did not give their medication on time. LPA Brown unable to obtain information from two (2) residents/clients as they were unable to answer LPA Brown's questions. Staffs' interviews indicated that the residents/clients at the facility are receiving and taking their medications per schedule, per their doctor's order daily. Staffs' interviews revealed that all staffs at the facility make sure that their residents/clients are taking their medications on time and there's no incident that they did not give their resident/client medications on a timely basis. During the visit on 07/21/2023, LPA Brown reviewed Client #2 (C2) and Client #3 (C3) Medication Administration Records (MAR) and LPA Brown observed that C2 and C3 are receiving their medications on time, per their doctors' order.

The sixth allegation indicates Facility staff are not following reporting requirements. Interviews with residents indicated that they observed all staffs are reporting everything that are happening at the facility to their family or to their social workers. LPA Brown unable to obtain information from two (2) residents/clients as they were unable to answer LPA Brown's questions. Staffs' interviews indicated that they are required to document daily the incidents at the facility and all incidents are reported to residents/clients family, responsible party and appropriate state agency. Staffs interviews revealed that there's no incident that staffs at the facility did not follow their reporting requirements.

The seventh allegation indicates Facility falsifies residents' records. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with residents/clients indicated that they are not aware of an incident that the facility falsifies their records. LPA Brown unable to obtain information from two (2) residents/clients as they were unable to answer LPA Brown's questions. Interviews with staffs indicated that they did not witnessed or observed any incident that the facility falsifies residents'/clients records. Staff interviews revealed that there's no incident at the facility that a staff falsifies residents/clients record. Per documents review, LPA Brown did not observe signs that showed the facility falsifies residents/clients record.

The eight allegation indicates Staff are not adequately supervising residents. Interviews with residents/clients indicated that staffs are always supervising them, they are always with them, monitoring them and there's no incident that happened that a staff did not adequately supervise them. ***Continuation in LIC9099C ***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 56-AS-20220426100253
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: KAISER SPECIALIZED RESIDENTIAL SERRANO
FACILITY NUMBER: 366423573
VISIT DATE: 07/27/2023
NARRATIVE
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 Staffs interviews indicated that they are supervising all their clients/residents as their residents/clients needs one (1) staff to one (1) client supervision. Staffs interviews revealed that they are constantly supervising their residents/clients in care and there's no incident at the facility that they are not adequately supervising their clients. During the facility visit on 07/21/2023, LPA Brown observed staffs are appropriately and adequately supervising their clients. Per documents review, LPA Brown observed sufficient number of staffs scheduled per shift to adequately supervise their clients in care.

The ninth allegation indicates Facility staff sleeps while on the job. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with residents/clients indicated that no staffs at the facility sleeps while on the job and no incident happened that a staff sleeps while on the job. LPA Brown unable to obtain information from two (2) residents/clients as they were unable to answer LPA Brown's questions. Staffs' interviews indicated that they are not sleeping while on the job and no staff at the facility sleeps while on the job. Staffs interviews revealed that they are not aware of an incident at the facility that a staff sleeps while on the job. During the facility visit on 07/21/2023, LPA Brown observed all staffs assisting and monitoring residents/clients in care and no staff at the facility sleeps while on the job.

The tenth allegation indicates Facility staff refuse to give some residents food. Interviews with residents/clients indicated that staffs always gives them food when they asked for food and no staff at the facility refused to give them food. LPA Brown unable to obtain information from two (2) residents/clients as they were unable to answer LPA Brown's questions. Staffs interviews indicated that they never refused a resident/client food and there's no incident at the facility that a staff refuse to give their resident/client food. During the facility visit on 07/21/2023, LPA Brown observed staffs giving food to clients that requested food and no staff refused to give their resident/clients food.

Based on interviews, observation and records review, the allegations Staff are not following resident's care plan (Allegation #1), Staff did not respond to resident's request for care services in a timely manner (Allegation #2), Staff verbally abuse residents in care (Allegation #3), Facility does not have sufficient food for residents in care (Allegation #4), Residents are not receiving medications on a timely basis (Allegation #5), Facility staff are not following reporting requirements (Allegation #6), Facility falsifies residents' records (Allegation #7), Staff are not adequately supervising residents (Allegation #8), Facility staff sleep while on the job (Allegation #9), Facility staff refuse to give some residents food (Allegation #10) are UNSUBSTANTIATED. **Continuation on LIC9099C*

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 56-AS-20220426100253
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: KAISER SPECIALIZED RESIDENTIAL SERRANO
FACILITY NUMBER: 366423573
VISIT DATE: 07/27/2023
NARRATIVE
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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 violations did or did not occur.

An exit interview was conducted, where this report (LIC9099) was discussed and provided to House Manager/Administrator Elizabeth Gonzalez.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5