<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200967
Report Date: 02/24/2026
Date Signed: 02/24/2026 05:18:34 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
10/31/2025 and conducted by Evaluator Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20251031101324
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: DATE:
02/24/2026
UNANNOUNCEDTIME BEGAN:
04:40 PM
MET WITH:Annabel Danan, House ManagerTIME COMPLETED:
05:25 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not allowing resident to return to the facility

Staff do not ensure that resident's medication is refilled in a timely manner
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 1/24/2026 at 4:40pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver a complaint finding for the allegations above. LPA met with Annabel Danan, House Manger, and explained the reason for the visit.

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

Allegation: Staff are not allowing resident to return to the facility

During the initial interview W1 reported that the facility is not allowing R1 to return to the facility due to nonpayment. W1 stated S2 advised that R1 could

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

DATE: 02/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2026
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-20251031101324
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: 02/24/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC9099.

not return without payment for the time R1 has resided at the facility and a 30-day notice would not be given. W2 stated during interview that R1 was not sick R1 was dropped off with a note and left at the hospital. S3 stated during interview that R1 was taken to the hospital by S2 and S3 for medication. S3 had no further information regarding R1. During interview with S2 on 2/18/2026, S2 stated that R1 was not allowed to return to the facility with a contract from Kaiser.
Allegation: Staff do not ensure that resident's medication is refilled in a timely manner

During the initial interview W1 was informed on 10/15/2025 that R1 was out of medication. W1 reported R1 had an appointment on 10/23/2025, however, staff did not pick up R1’s medication until 10/29/2025. S1 stated during interview that R1 was out of two medications. Staff tried to contact CCHP (Contra Costa Health Plan) but did not receive a response. During interview S1, S2, and S3 stated R1 did not have any medication and there was an insurance issue. S2 stated R1 was taken to emergency due to not having any medications. LPA also reviewed a copy of the note that was given to R1 that stated R1 did not have any medication for three weeks.

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: 02/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20251031101324
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: 02/24/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/03/2026
Section Cited
CCR
87224(c)
1
2
3
4
5
6
7
(c) The licensee shall, in addition to either serving the required thirty (30)... notify or mail a copy of the notice to the resident's responsible person.
This requirement was not met as evidence by:
1
2
3
4
5
6
7
Administrator agreed to review regulation 87224 and submit a self-certification that the facility will abide by the regulation going forward and submit the self-certification to CCLD by the POC date.
8
9
10
11
12
13
14
Based on interviews and record review the Licensee did not comply with the section cited above in not letting R1 return to the facility and did not issue an eviction notice, which poses a potential person rights issue to persons in care.
8
9
10
11
12
13
14
Type B
03/03/2026
Section Cited
CCR
87465(a)
1
2
3
4
5
6
7
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical... and provide for assistance in obtaining such care...
This requirement was not met as evidence by:
1
2
3
4
5
6
7
: Administrator agreed to implement a plan for staff when a resident have not received their medication and submit plan to CCLD by POC date.
8
9
10
11
12
13
14
Based on interviews and record reviews, the Licensee did not comply with the section cited above in helping R1 obtain medication, which poses a potential health issue to person in care.
8
9
10
11
12
13
14
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: 02/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3