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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200967
Report Date: 10/14/2025
Date Signed: 10/14/2025 05:44:11 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/24/2025 and conducted by Evaluator Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250624160351
FACILITY NAME:SERENE CARE JACQUELINEFACILITY NUMBER:
079200967
ADMINISTRATOR:RANCES, RONAN BFACILITY TYPE:
740
ADDRESS:2297 JACQUELINE DRIVETELEPHONE:
(925) 635-3474
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY:6CENSUS: 5DATE:
10/14/2025
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Annabel Danan, House ManagerTIME COMPLETED:
05:05 PM
ALLEGATION(S):
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Licensee is retaining a resident with a higher level of care need.

Resident sustained a pressure injury due to staff neglect.
INVESTIGATION FINDINGS:
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On 10/14/2025, at 2:30pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver a complaint finding for the allegations above. LPA met with Annabel Danan, House Manager, and explained the reason for the visit. LPA spoke with Administrator, Isagani Silvestre, via telephone.

During the course of the investigation the Department conducted interviews with staff, witnesses, obtained and reviewed documentation.

Allegation: Licensee is retaining a resident with a higher level of care need.

During the initial interview W1 stated that the facility was retaining a resident

Continued on LIC9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
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 15-AS-20250624160351
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SERENE CARE JACQUELINE
FACILITY NUMBER: 079200967
VISIT DATE: 10/14/2025
NARRATIVE
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Continued from LIC9099.

that required a higher level of care. W1 stated that R1 has prohibited health condition, and the staff were not trained in how to assist R1 with the condition when needed. R1 was admitted to the facility 01/01/2025. The prohibited health condition that R1 has requires the facility to request an exception prior to admission, however, the facility did not submit a request for the exception. R1 was admitted into hospice services on 4/30/2025. R1 expired on 9/4/2025.

Allegation: Resident sustained a pressure injury due to staff neglect.

During the initial interview W1 stated resident sustained a pressure injury due to staff neglect. W1 stated R1 had a wound on her finger and one on her foot. W1 was unsure if the facility staff was trained how to position R1. During interview on 10/14/2025, both S1 and S2 stated that R1 had a wound on her left heel. S1 stated pillows were placed near bottom of R1's body due to her diagnosis. LPA did not observe any documentation that facility contacted any medical professional regarding wounds.

Based on interviews which were conducted, record review, and observation the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. A copy of the appeal rights and this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20250624160351
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SERENE CARE JACQUELINE
FACILITY NUMBER: 079200967
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/21/2025
Section Cited
CCR
87616(a)
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(a) As specified in Section 87209... the licensee may submit a written exception request if he/she agrees that the resident has a prohibited ... health condition but believes that the intent of the law can be met through alternative means. This requirement was not met as evidence by:
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Administrator agreed to review regulation 87616 and 87615. Administrator will submit self-certification that both have been read and they abide by the regulations going forward to CCLD by POC date.
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Based on interviews and documentation, the Licensee did not comply with the section cited above in requesting an exception before admitted a resident with a prohibited condition, which poses a health risk to person in care.
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Type B
10/21/2025
Section Cited
HSC
1569.269(a)(6)
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(a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff... qualifications... to meet their needs. This requirement was not met as evidence by:
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Administrator agreed to implement a plan on how to prevent residents from developing pressure injuries. Plan needs to be submitted to CCL by POC date.
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Based on interviews and observation the Licensee did not comply with the section cited above in preventing R1 from obtaining wounds, which poses a health risk to person in care.
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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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3