197603050-4-12-2022-29-AS-JAPL-CEHUBD-20220517152609

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603050
Report Date: 04/12/2022
Date Signed: 04/12/2022 08:51:53 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/15/2021 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20211115153411

FACILITY NAME:	VILLA SERRANO CARE HOME		FACILITY NUMBER:	197603050
ADMINISTRATOR:	PACITA R. SERRANO		FACILITY TYPE:	735
ADDRESS:	11937 COHASSET STREET		TELEPHONE:	(818) 503-7124
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	6	CENSUS: 5	DATE:	04/12/2022
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Pacita Serrano		TIME COMPLETED:	01:43 PM

ALLEGATION(S):

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Unexplained death.

INVESTIGATION FINDINGS:

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This is an amended report. On 03/18/2022, Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent visit at 10:00 a.m. to deliver the findings for the above allegation. The LPA was greeted by staff and informed staff about the visit. The staff contacted the Administrator via phone. The LPA spoke with the Administrator and explained the reason for the visit. The Administrator stated that they would not be able to be at the facility, and instructed the designated staff to sign off on today’s report.

Continues on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

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

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20211115153411

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLA SERRANO CARE HOME	FACILITY NUMBER: 197603050
	VISIT DATE: 04/12/2022

NARRATIVE

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On 11/16/2021, at approximately 9:30am, Licensing Program Analyst (LPA), Sandra Urena arrived at the facility to conduct an unannounced investigation visit regarding the allegations above. The caregiver greeted LPA Urena and stated that the Licensee, Pacita Serrano, was not present. The caregiver proceeded to call the Licensee to inform them of the visit. At 9:45 a.m., LPA Urena spoke with the Licensee on the phone and explained the reason for today’s visit. LPA Urena obtained and reviewed records from 9:55 a.m. to 10:30 a.m.; and, conducted interviews with staff and residents from 10:35 a.m. to 11:20 a.m.

On the allegation of ‘Unexplained death’, it is alleged that the Resident #1(R1) died due to the neglect by the facility staff. It was expressed that when the paramedics were called, R1 was had already passed. Furthermore, the complainant stated that the paramedics were called because ‘the patient had a stomach problem’. To investigate this allegation the LPA conducted staff interviews, resident interviews, and reviewed pertinent records to the allegation.

On 11/16/2021, at approximately 10:35 a.m., the LPA interviewed the Staff #1(S1). S1 stated the following: On 11/11/2021, at approximately 11:45 p.m., S1 stated that they were getting ready for bed, first by going to the bathroom, when S1 heard a scream and heard Resident # 1(R1), say “Mama, mama”. S1 stated that they finished using the bathroom, then went to look into the R1’s room. At this point, S1 found R1’s mouth open and eyes were rolled back towards the top of R1’s head. S1 stated that the R1, ‘was dead’. S1 stated that S1 checked for R1’s pulse and there was no pulse. S1 stated that they didn’t perform CPR because R1 was dead with their mouth open. The S1 stated that they proceeded to go look for Resident #2 (R2) to get the R2’s assistance, because the R2 spoke the same language as R1. Both S1 and R2 went to see R1 in the bedroom, and at this time R2 stated to S1, “R1 is dead”. LPA Urena asked the S1 if the R1 had complained of pain or not feeling well on 11/11/2021? S1 stated, ‘No, I took R1’s temperature and the R1 was ok, no fever’. Per S1, they proceeded to call 9-1-1, then the administrator, Pacita Serrano.

On 11/16/2021 at approximately 11:10 a.m., the LPA interviewed the administrator about the incident. The administrator stated that S1 called them with the news of R1’s death. The following is a timeline about the events as explained by the administrator. At approximately 12:16 a.m., the administrator received a call from S1 to inform them about R1’ death. Per the administrator, S1 stated the following, ‘R1 is dead, they are not breathing’. At 1:10 a.m., the administrator called the Los Angeles Regional Center to report the death of R1. At 1:40 a.m., the Los Angeles Police Department (LAPD) arrived and took a report. At 3:00 a.m., the administrator contacted responsible party for R1. At 4:50 a.m., the funeral home arrived to pick up R1’s body.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20211115153411

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLA SERRANO CARE HOME	FACILITY NUMBER: 197603050
	VISIT DATE: 04/12/2022

NARRATIVE

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On 03/18/2022 at approximately 11:15 a.m., LPA Urena contacted R1’s Responsible Party (RP). LPA Urena interviewed RP and asked pertinent questions related to the allegations. The RP stated that they were aware of R1’s heart disease and that R1 was being seen by a cardiologist. Furthermore, RP stated that R1 had resided at the facility for many years. The RP stated that they visited R1 often, would take R1 on outings and for overnight weekend stays at their house. The RP stated that R1 was well taken care by caregivers and they never had concerns of neglect or abuse. The RP stated that the administrator informed them of R1’s death on 11/12/2021. The R1’s responsible parties stated that they were satisfied with the care that R1 received at the facility.

The LPA obtained and reviewed the Death Report for R1. The Death Report issued by the State of California on 11/19/2021 states the following: The findings of the autopsy state that R1’s ‘Manner of death, natural causes’. 'Immediate cause of death, Cardiac Dysfunction and Atherosclerosis Heart Disease.’

Based on the information obtained, there is insufficient evidence to support the claim that resident died of an ‘unexplained death’ due to staff negligence. This allegation is deemed Unsubstantiated at this time.

No citations were issued today. Report was reviewed with administrator, signatures were gathered. A copy of the report was issued via email.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC9099 (FAS) - (06/04)

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