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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525002790
Report Date: 03/05/2024
Date Signed: 03/05/2024 02:37:36 PM

Document Has Been Signed on 03/05/2024 02:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SERENITY RESIDENTIALFACILITY NUMBER:
525002790
ADMINISTRATOR:PHELPS, ASHLEYFACILITY TYPE:
735
ADDRESS:925 FRANKLIN STTELEPHONE:
(530) 200-2909
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY: 4CENSUS: 4DATE:
03/05/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Ashley Phelps - licenseeTIME COMPLETED:
03:00 PM
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03/05/2024 10:00 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with licensee Ashley Phelps. Today’s visit is regarding an incident that occurred on 02/27/2024 and was reported by the facility to licensing on 02/28/2024.

It was reported that Client 1 (C1) told day program staff that Staff 1 (S1) at their house pushed and kicked C1. Licensee conducted an internal investigation which included reviewing surveillance video within the home and found C1’s claims to be accurate. Licensee attempted to contact S1 who immediately quit and refused to cooperate with the internal investigation. Event happened at 2:50 AM on 2/27/2024. C1 woke up at 2:45 AM to use the bathroom. When C1 went to wash their hands their roommate, Client 2 (C2) ran into the bathroom to use it. C1 tried walking back to the bathroom and S1 shoved C1. C1 raised their hand and tried to hit S1, then S1 shoved C1 again and pushed C1 all the way into their room. After C1 washed their hands, S1 was sitting in a chair by the front door. C1 raised both fists and walked towards S1. S1 then raised their foot and kicked C1 back away from S1. C1 went back to their room to sleep for the night. S1 has resigned their position at the facility.

During the visit LPA reviewed the security camera footage, interviewed the licensee and house manager and requested the following documents: Physician's Report, IPP, Admission Agreement for 1 client and employment application, DOJ clearance,and contact information for 1 staff. LPA reviewed multiple behavioral trainings that S1 had completed while employed at the facility. Licensee sent the security camera footage to LPA via text message and will also email the footage.

Continued on LIC809-C

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SERENITY RESIDENTIAL
FACILITY NUMBER: 525002790
VISIT DATE: 03/05/2024
NARRATIVE
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During the investigation it was learned that C1 was not injured during the interaction with staff. LPA viewed security camera footage which showed S1 striking C1, S1 pushing C1 and S1 kicking C1.

It was determined that Staff 1 (S1) used physical force against Client 1 (C1) which constitutes abuse. The allegation that staff physically abused a client is substantiated.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted and the report was provided to licensee Ashley Phelps.

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/05/2024 02:37 PM - It Cannot Be Edited


Created By: Rebecca Knight On 03/05/2024 at 08:37 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SERENITY RESIDENTIAL
FACILITY NUMBER: 525002790

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/19/2024
Section Cited
CCR
80072(a)(3)

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80072(a)(3) Personal Rights - Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including... toileting. This requirement is not met as evidenced by:
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Licensee agrees to submit a plan of correction advising how this type of violation will be avoided in the future.Licensee will submit the plan to LPA as the POC.
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Based on interviews and LPA review of surveillance camera footage it was determined that Staff 1 physically abused 1 of 4 clients. This poses an immediate health and safety risk to clients in care.
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The proof of correction is to be received by LPA Knight by 03/19/2024.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lauren Crocker
LICENSING EVALUATOR NAME:Rebecca Knight
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024


LIC809 (FAS) - (06/04)
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