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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486802085
Report Date: 07/16/2021
Date Signed: 07/21/2021 12:32:05 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/04/2021 and conducted by Evaluator Katrina Walters
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20210304082028
FACILITY NAME:BUCK SERENITY HOMESFACILITY NUMBER:
486802085
ADMINISTRATOR:CASTRO, GIDEONFACILITY TYPE:
740
ADDRESS:691 BUCK AVENUETELEPHONE:
(707) 449-8394
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY:6CENSUS: 4DATE:
07/16/2021
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Gideon CastroTIME COMPLETED:
12:10 PM
ALLEGATION(S):
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Staff failed to execute emergency disaster plan
Staff failed to provide care and supervision to resident
INVESTIGATION FINDINGS:
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**Amended** Licensing Program Analysts (LPAs) Katrina Walters and Jill Nakagawa conducted an unannounced complaint visit and met with Administrator, Gideon Castro. The purpose of the visit is to deliver findings for the allegations listed above.

The complainant alleged that on 08/19/2020 during LNU lightning fire, the facility failed to execute emergency disaster plan and that Staff failed to provide care and supervision to residents.

During the course of this investigation, LPA virtually toured the facility by way of Administrator on 3/11/21, interviewed staff and various outside parties, reviewed the facilities emergency disaster plan dated 9/25/18, reviewed resident records, reviewed videos and made observations.
Continued on 9099 C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
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 7
Control Number 21-AS-20210304082028
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: BUCK SERENITY HOMES
FACILITY NUMBER: 486802085
VISIT DATE: 07/16/2021
NARRATIVE
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**Amended** Continued from 9099

Based on interviews conducted and documents gathered LPA learned that the facility provided an emergency plan to the resident’s responsible parties which is different then the Emergency Disaster Plan on file with Community Care Licensing (CCL). Interviews further revealed that on 8/19/20, when the facility received a mandatory evacuation notification due to approaching fires the facility did not follow the emergency disaster plan that was on file with CCL which identified two evacuations sites and a transportation plan different than what was executed.

Based on interviews with the administrator, staff and various outside parties LPA learned that upon being alerted that the facility was to be evacuated, the Administrator contacted two of four residents (R2 &R3) responsible parties and asked that they transport the residents to an evacuation location of their own. One of four residents (R1) responsible party arrived at the facility and picked up R1 from the facility before the Administrator could call. Because residents (R4) responsible party lived out of the area facility staff allowed R4 to be transported by another resident’s responsible party (video footage on file). A review of R4s care plan identifies that the resident requires 24-hour care and supervision. R4 remained with this individual, who was not R4’s responsible party or staff member for several hours before they were able to make contact with the licensee and make arrangements to transport R4 to staff (S1’s) residence rather than the evacuation site identified on the facility’s emergency plan. The Administrator then picked up R4 and transported them to the evacuation location. Although R4s responsible party was notified of the evacuation Licensee did not to provide full details how R4 was evacuated and where they were initially evacuated to.


Continued on 9099 C

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 21-AS-20210304082028
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: BUCK SERENITY HOMES
FACILITY NUMBER: 486802085
VISIT DATE: 07/16/2021
NARRATIVE
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**Amended** Continued from 9099 C

Based upon statements received, records reviewed and video footage it was determined that the Licensee did not evacuate residents to the two emergency sites listed on the facility emergency disaster plan dated 9/25/18 and because R4 was required to remain with R1s responsible party for several hours following the evacuation, it is determined that staff failed to provide care and supervision for R4. Therefore, both allegations are SUBSTANTIATED.

Based upon the records reviewed and statements received during interviews the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations and or Health Safety Code, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/04/2021 and conducted by Evaluator Katrina Walters
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20210304082028

FACILITY NAME:BUCK SERENITY HOMESFACILITY NUMBER:
486802085
ADMINISTRATOR:CASTRO, GIDEONFACILITY TYPE:
740
ADDRESS:691 BUCK AVENUETELEPHONE:
(707) 449-8394
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY:6CENSUS: 4DATE:
07/16/2021
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Gideon CastroTIME COMPLETED:
12:10 PM
ALLEGATION(S):
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2
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9
Facility failed to report incident
INVESTIGATION FINDINGS:
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12
13
**Amended** On 7/16/2021 Licensing Program Analyst (LPA) Katrina Walters and Jill Nakagawa conducted an unannounced complaint visit and met with Administrator, Gideon Castro. The purpose of the visit is to deliver findings for the allegations listed above.

During the course of this investigation LPA virtually toured the facility with Administrator on 3/11/21, interviewed staff and various outside parties, reviewed the facility’s emergency disaster plan dated 9/25/18 as well as the emergency disaster plan provided to residents and their responsible parties, reviewed resident records, reviewed videos and made observations. The complainant alleges that the facility failed to submit a Special Incident Report to Community Care Licensing (CCL) that they were required to evacuate on 8/19/20 during a the 2020 LNU fires. Based on a record review LPA confirmed that the Administrator reported the evacuation to Community Care Licensing on 8/19/20.

This agency has investigated the complaint alleging that facility failed to report the evacuation incident. 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.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/04/2021 and conducted by Evaluator Katrina Walters
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20210304082028

FACILITY NAME:BUCK SERENITY HOMESFACILITY NUMBER:
486802085
ADMINISTRATOR:CASTRO, GIDEONFACILITY TYPE:
740
ADDRESS:691 BUCK AVENUETELEPHONE:
(707) 449-8394
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY:6CENSUS: 4DATE:
07/16/2021
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Gideon CastroTIME COMPLETED:
12:10 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Facility did not have transportation to evacuate all residents
INVESTIGATION FINDINGS:
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3
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5
6
7
8
9
10
11
12
13
**Amended** On 7/16/2021 Licensing Program Analysts (LPAa) Katrina Walters and Jill Nakagawa conducted an unannounced complaint visit and met with Administrator, Gideon Castro. The purpose of the visit is to deliver findings for the allegation listed above.

During the course of this investigation LPA virtually toured the facility with Administrator on 3/11/21, interviewed staff and various outside parties, reviewed the facilities emergency disaster plan dated 9/25/18 as well as the emergency disaster plan provided to residents and their responsible parties, reviewed resident records, reviewed videos and made observations.

Continued on 9099 C

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 21-AS-20210304082028
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: BUCK SERENITY HOMES
FACILITY NUMBER: 486802085
VISIT DATE: 07/16/2021
NARRATIVE
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**Amended** It was alleged that Facility did not have transportation to evacuate all residents during a mandatory evacuation on 8/19/20 due to a wildfire. Based on Interviews conducted with staff and various outside parties, LPA's observations and records reviewed LPA learned the following: Per the Administrator the facility had transportation, but did not transport resident as outlined in their disaster plan to transport residents to safety (failure to use their vehicles is cited under the allegation that facility failed to execute facility’s emergency disaster plan). Instead responsible parties were asked that they transport residents to a safe location. Although interviews with staff and outside parties confirmed that transportation was there, LPA was unable to prove or disprove if the transportation would support all residents.

A finding that the complaint allegation facility did not have transportation to evacuate all residents is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 21-AS-20210304082028
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: BUCK SERENITY HOMES
FACILITY NUMBER: 486802085
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/19/2021
Section Cited
HSC
1569.695(a)(1)
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HSC 1569.695 Emergency Plans 1569.695(a)(1)...a residential care facility for the elderly shall have an emergency plan that shall include..(1) Evacuation procedures. This requirement was not met as evidenced by: based on interviews &
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Licensee agrees to review HSC 1569.695 and update facilities LIC 610E, licensee to review the regulation and updated emergency plan with all staff using sign in sheet, licensee to provide
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record reviews, licensee failed to ensure the facility’s emergency plan sent to CCL was implemented 8/19/20 during mandatory evacuation. This posed an immediate health & safety risk to the residents in care.
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a copy of the updated plan to residents and responsible parties and send LIC 610E, sign-in sheet to LPA by POC due 7/24/21. Licensee to create a plan of how they will ensure future compliance POC due 7/23/21.

Type A
07/19/2021
Section Cited
HSC
1569.269(a)(6)
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HSC 1569.269(a)(6) Enumerated Rights: 1569.269(a)(6) Residents of residential care facilities for the elderly shall have all of the following rights: To care, supervision, and services that meet their individual needs and
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Administrator to submit a self-certification that they have reviewed regulation regarding Care and Supervision and submit plan to CCL of how they will ensure future compliance to all residents in the event of an
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are delivered by staff..This requirement was not met as evidenced by: based on interviews and record review, the licensee failed to ensure adequate supervision was provided to 1 of 4 residents on 8/19/20, which posed an immediate health & safety risk to the residents in care.
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evacuation to CCL by POC date of 07/16/2021.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 7