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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435201883
Report Date: 02/23/2024
Date Signed: 02/26/2024 08:04:35 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/04/2022 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20220504135515
FACILITY NAME:SERENITY CARE HOME RCFEFACILITY NUMBER:
435201883
ADMINISTRATOR:MELBURGA SENOTFACILITY TYPE:
740
ADDRESS:684 LAKEWOOD DRTELEPHONE:
(408) 747-3439
CITY:SUNNYVALESTATE: CAZIP CODE:
94089
CAPACITY:6CENSUS: 4DATE:
02/23/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Olga MelburgaTIME COMPLETED:
10:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Lack of supervision resulting in resident leaving the facility.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 2/22/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegation. LPA met with Admininstrator Olga Melburga and LPA explained the purpose of the visit.

Regarding the allegation of lack of supervision resulting in resident leaving the facility. The reporting party (RP) stated that the primary concern is that the client (R1) wanders a lot and SA may not be able to provide adequate supervision or care.

LPA interviewed the admininstrator, Olga Melburga (S1). S1 mentioned that R1 never left the facility unaccompanied or unassisted. S1 is always accompanying R1 whenever he/she goes out of the facility. S1 also brings R1 to do grocery shopping.

Based on interviews, the department has determined that that the allegations were false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED. No deficiencies cited today. Report is reviewed and copy is provided.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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