435202729-8-28-2024-26-AS-KHOS-D8RGRM-20240903053433

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202729
Report Date: 08/28/2024
Date Signed: 08/28/2024 12:04:00 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/12/2023 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20231212135803

FACILITY NAME:	SERENITY HOME		FACILITY NUMBER:	435202729
ADMINISTRATOR:	MURILLO, JENNIFER		FACILITY TYPE:	737
ADDRESS:	17390 SERENE DRIVE		TELEPHONE:	(831) 818-7981
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY:	4	CENSUS: 3	DATE:	08/28/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Lucero Rodriguez and David Sandhu		TIME COMPLETED:	11:50 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is not maintaining centrally stored medication record
Staff neglected resident
Residents cash resources are coming up short
Facility staff abused resident by forcing residents to go on outings
Staff are under the influence of drugs while on duty
Staff are engaging in inappropriate sexual activity in the facility

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding of the above allegations. LPA met with Administrator, Lucero Rodriguez and Director of Operations, David Sandhu.

On 12/12/2023, the Department received the complaint regarding the above allegations. On 12/20/2023, the initial complaint investigation was conducted.

The following documents were obtained to include the resident roster, staff roster (LIC 500), activities calendar from October - December, IPPs for resident (R1) – (R3), P&I logs, centrally stored medication records, drug and alcohol policy, and staff schedule from November to December 2023. PAGE 1 OF 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

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 3

Control Number 26-AS-20231212135803

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SERENITY HOME	FACILITY NUMBER: 435202729
	VISIT DATE: 08/28/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Facility is not maintaining centrally stored medication record
On 12/20/2023, 3 out of 3 resident’s centrally stored medications and centrally stored medication records were inspected. 3 out of 3 resident’s medications observed to be accounted. On 10/13/2023, LPA Dolores inspected 3 resident’s centrally stored medications and records during an unannounced annual inspection. No issues were noted regarding the resident’s medications during the visit.

Staff neglected resident
It was alleged that a resident gets neglected.

3 staff members were interviewed. Based on interview, 3 out of 3 staff denied residents being neglected.

1 resident was interviewed. Based on interview, it was stated the resident feels neglected by 1 staff member. It was stated that all the other staff treated resident with respect.

Residents cash resources are coming up short
On 12/20/2023, 3 out of 3 resident’s P&I money were inspected. 3 out of 3 residents P&I money observed to be maintained without shortage of money. On 10/13/2023 and 11/02/2023, LPA Dolores inspected 3 resident’s P&I money during an unannounced visit. No issues were noted regarding the resident’s P&I money during the visits.

Facility staff abused resident by forcing residents to go on outings
Throughout the investigation, 3 staff members were interviewed. Based on interview, it was stated that 3 out of 3 residents are very vocal and would verbalize if they forced to do something they don’t want to do. 3 out of 3 staff denied forcing any residents to go on outings.

1 resident was interviewed. Based on resident interview, it was stated staff forced the resident to go on an outing the week of August 19, 2024. It was stated the resident wanted to go on their own outing but the staff forced him/her to go on the facility's outing. PAGE 2 OF 3.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20231212135803

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SERENITY HOME	FACILITY NUMBER: 435202729
	VISIT DATE: 08/28/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Staff are under the influence of drugs while on duty
On 12/20/2023, during staff interviews it was stated that a staff was suspended after being witnessed smoking marijuana in between shifts. The staff was not allowed to continue work and was sent to the office right away. It was also stated that a second staff was suspended after the observation of smelling like marijuana.

On 01/02/2023, the Department was notified of a third staff who was suspended after leadership staff physically observed this staff smoking during their break-time. It was stated that the staff smelled like marijuana and was immediately sent home.

Residents were not affected by these incidents.

1 resident was interviewed. Based on interview, resident has not observed inappropriate behavior with the staff.

Based on record review, the facility has a drug and alcohol use policy that includes prohibition of marijuana use in the workplace. Staff are required to sign the agreement during the hiring process.

Staff are engaging in inappropriate sexual activity in the facility
2 staff were interviewed. Based on interview, this allegation happened in another care facility. After the incident, the staff members were separated and one of the staff was transitioned to another facility. 1 resident was interviewed. Based on interview, resident has not observed inappropriate behavior with the staff.

The Department has investigated the above allegations. Based on interviews, record review and observation the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegations may have happened and/or is valid there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Lucero Rodriguez and Director of Operations, David Sandhu and a copy of the report was provided. PAGE 3 OF 3.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3