306005803-11-3-2021-22-AS-MVAO-CBGS4F-20220209123239

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005803
Report Date: 11/03/2021
Date Signed: 11/03/2021 02:54:56 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/23/2021 and conducted by Evaluator Albert Marin

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210823102714

FACILITY NAME:	A TOUCH OF SERENITY RESIDENTIAL CARE		FACILITY NUMBER:	306005803
ADMINISTRATOR:	REYES, NAYEHY		FACILITY TYPE:	740
ADDRESS:	24562 ARTEMIA AVE		TELEPHONE:	(949) 633-5336
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 4	DATE:	11/03/2021
		UNANNOUNCED	TIME BEGAN:	02:24 PM
MET WITH:	Administrator Juan Reyes		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Licensee did not administer oxygen to resident as ordered.
Unlawful eviction of a resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to this facility. LPA met with Administrator Juan Reyes and stated the purpose of the visit. The purpose of the visit was to deliver the findings on the investigation completed for the complaint filed against this facility last August 23, 2021.

On allegation Licensee did not administer oxygen to resident as ordered, the following are the findings. On September 26,2020 4:00 PM, Resident 1 (R1) was seen and evaluated by skilled medical professional. R1 was not in pain nor in distress but confused and agitated. Vital signs were taken and recorded to be within normal limits with respiratory rate of 18 per minute, oxygen saturation at 97% at room air with clear lung sounds but diminished at the bases. An order of 2-5 liters of oxygen per minute via nasal cannula and mask as needed was made on admission. Hospice admission was completed at 7:00 PM. At 3:49 AM of September 27, 2020, the hospice received a report from the facility that R1 had troubled breathing. Via video conference, R1 was on recliner on oxygen therapy. Moments after, R1 was reassessed via video conference and R1 was observed to comfortable, sleeping and with no signs of respiratory distress. (Continuation in page 2)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021

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 4

Control Number 22-AS-20210823102714

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: A TOUCH OF SERENITY RESIDENTIAL CARE	FACILITY NUMBER: 306005803
	VISIT DATE: 11/03/2021

NARRATIVE

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(Continuation from Page 2) Based on the information gathered during the investigation and review of documents obtained, the LPA is unable to ascertain if the allegation occurred as reported.Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED.

On allegation of unlawful eviction of a resident, the following are the findings. On September 18, 2020, Resident 1 (R1) was admitted in the facility. On the same date, the facility issues two invoice statements. The first statement described the prorated basic services fee for September and the preadmission appraisal fee; and the second statement described the basic services fee for October 2020. Per file review, LPA observed two checks that paid the amount in full as described in the first statement; but no document was provided to support if full payment was made for October 2020. On September 26, 2020, R1 was placed under hospice care and determined that it was necessary to place R1 under 1:1 particularly during night shifts to address R1’s needs. On September 29, 2020, both parties agreed in writing that the services for R1 will end on September 30,2020 and any additional days and services will be pro-rated and charged separately. R1 was transferred to another facility. Thus, the allegation of unlawful eviction of a resident is UNSUBSTANTIATED.

LPA Marin conducted an exit interview with AD Juan Reyes, and copies of this report was left in the facility.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/23/2021 and conducted by Evaluator Albert Marin

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210823102714

FACILITY NAME:	A TOUCH OF SERENITY RESIDENTIAL CARE		FACILITY NUMBER:	306005803
ADMINISTRATOR:	REYES, NAYEHY		FACILITY TYPE:	740
ADDRESS:	24562 ARTEMIA AVE		TELEPHONE:	(949) 633-5336
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 4	DATE:	11/03/2021
		UNANNOUNCED	TIME BEGAN:	02:24 PM
MET WITH:	Administrator Juan Reyes		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Licensee yells at resident(s).

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to this facility. LPA met with Administrator Juan Reyes and stated the purpose of the visit. The purpose of the visit was to deliver the findings on the investigation completed for the complaint filed against this facility last August 23, 2021.

On allegation that Licensee yells at resident(s), the following are the findings. Based on interviews and observation, the Licensee had been stern in giving instructions and reminder to visitors about infection control procedures of the facility. Four out of four witnesses interviewed stated that they did not observe the licensee, or any staff yelled at any resident. Thu the allegation was unfounded.

This agency has investigated the complaint alleging that Licensee yells at resident(s). We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

LPA Marin conducted an exit interview with AD Juan Reyes, and copy of this report was left in the facility.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4