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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604474
Report Date: 10/09/2024
Date Signed: 10/09/2024 04:58:29 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/02/2024 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20241002143614
FACILITY NAME:VISTA SERENO RCFEFACILITY NUMBER:
374604474
ADMINISTRATOR:MASE, DOMINIQUEFACILITY TYPE:
740
ADDRESS:2725 VISTA SERENO CT.TELEPHONE:
(619) 405-3586
CITY:LEMON GROVESTATE: CAZIP CODE:
91945
CAPACITY:4CENSUS: 4DATE:
10/09/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Licensee Domininique MaseTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Licensee had an incomplete file for administrator
Licensee staff are not adequately trained
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to investigate a complaint and deliver investigative findings. LPA introduced herself, was granted entry into the facility, and met with Care giver Raturat Felimon to whom she disclosed the reason for the visit. Later Licensee/Administrator Domininique Mase joined the visit.

It was reported to Community Care Licensing (CCL) on 10/2/2024 that Licensee had and incomplete file for the administrator and staff are not adequately trained.

The Department’s investigation consisted of staff and client interviews, record reviews and outside source interviews.
(Continued on 1099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024
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 2
Control Number 08-AS-20241002143614
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: VISTA SERENO RCFE
FACILITY NUMBER: 374604474
VISIT DATE: 10/09/2024
NARRATIVE
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(Continued from 1099)

According to a review of records, all Licensee staff are adequately trained, and documentation is on file at Licensee facility. The regulations do state, HSC 1569.69(If Facility Capacity is 15 or Fewer: Ten (10) total hours of training on medication assistance, of which Six (6) hours must be hands-on training and four (4) hours will be other instruction.) and CCR 87411(c)(1) HSC 1569.618(b)(3), HSC 1569.618(c)(3)(First Aid Training Card/Certificate and Cardiopulmonary Resuscitation (CPR) ) as well as other Title 22 regulation required training be in completed before staff can work independently with clients. According to interview with the administrator, staff do have knowledge of training that was provided before staff started working independently with clients.

According to a review of records, the Administered file was present and did include all required documents. The regulations do state, staff should meet personnel requirements specified under code CCR 87411(c)(1) and HSC 1569.618(b)(3)( First Aid Training Card/Certificate “….from persons qualified by such agencies as the American Red Cross.) as well as CCR 87406 (Administrator Certification Requirements)

Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegation is not valid.

An exit interview was conducted with Licensee Domininique Mase A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Administrator and his signature on this report confirms receipt of the Licensee Rights.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2