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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603050
Report Date: 05/13/2022
Date Signed: 05/14/2022 09:50:21 AM

Substantiated


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 HOMEFACILITY NUMBER:
197603050
ADMINISTRATOR:PACITA R. SERRANOFACILITY TYPE:
735
ADDRESS:11937 COHASSET STREETTELEPHONE:
(818) 503-7124
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:6CENSUS: 5DATE:
05/13/2022
UNANNOUNCEDTIME BEGAN:
12:37 PM
MET WITH:Corazon BaldosTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility did not seek resident timely emergency medical attention.
INVESTIGATION FINDINGS:
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On 05/13/2022 at p.m., Licensing program Analyst (LPA) Sandra Urena, conducted a subsequent complaint visit to deliver the findings for the above allegation. At 12:03 p.m., the LPA was greeted by staff. Staff contacted via phone the Administrator Pacita Serrano, and the LPA explained the reason for the visit.

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 Administrator was not present. The caregiver proceeded to call the Administrator to inform them of the visit. At 9:45 a.m., LPA Urena spoke with the Administrator 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 from 10:35 a.m. to 11:20 a.m.


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
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 5
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: 05/13/2022
NARRATIVE
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On the allegation ‘Facility did not seek resident timely emergency medical attention’, it is alleged that the facility neglected resident #1 (R1). According to the Reporting Party (RP), the facility did not call for a first responder until the resident had already passed. The resident had abdominal pain for several days; however, medical care was not sought.

To initiate this investigation, on 11/16/21, at approximately 10:35 a.m., the LPA interviewed staff #1 (S1) who stated that R1 had not complained of pain or not feeling well during the week of 11/08/21. S1 stated that they were monitoring the residents for COVID-19 symptoms, such as fever, coughing or other symptoms. R1’s temperature was taken and there was no fever. R1 was staying in their room, including for meals, but S1 could not explain why R1 was isolating themselves.

On 11/16/2021 at approximately 11:10 a.m., the LPA interviewed the administrator about the above allegation. The administrator stated that during the week of 11/08/21, R1’s day program alerted the administrator that R1 was not their ‘usual alert.’ They stated that they would let R1 rest on a bed until it was time to take R1 back to the facility and the nurse would keep R1 under observation. When R1 returned to the facility, R1 was eating as usual and was alert with no symptoms. The facility staff was monitoring R1 for fever, coughing and any other COVID-19 related symptoms. The administrator stated that they called the doctor’s office to make an appointment for R1, but the earliest available appointment was for 11/11/2021 at 10:30 a.m. The administrator stated that they called the day program to inform them of the doctor’s appointment.

On 04/15/2022 at approximately 3:52 p.m., LPA Urena interviewed the Program Director (PD) for the day program attended by R1. LPA Urena asked the PD about R1’s physical demeanor during the week of 11/08/2021, and on the day of 11/09/2021, when R1 was noticed at the day program not to be their ‘usual alert’. The PD explained that R1 was usually talkative, alert and very active, going ‘up and down’ at the day program. However, on 11/09/2021, at around 8:45 a.m. the day program staff noticed that R1 was very quiet and was just sitting down. The PD stated that R1 said they were having stomach discomfort. The ED stated that the R1’s temperature was taken, and it registered at 97.0 degrees. Staff also noticed that the R1 was holding their abdomen where the colostomy bag was located. R1 reported to the staff that they had been in pain since they left the facility in the morning.

Continues on LIC 9099 C...

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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: 05/13/2022
NARRATIVE
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The staff asked R1 to rate their pain from 1- being the lowest, to 10 -being the highest. R1 answered, ‘10’. R1 also mentioned to the staff that they took pain medication before they left the facility in the morning. The day program staff communicated with the facility administrator to informed them of R1’s pain, and the administrator confirmed that they knew R1 was having pain and gave R1 pain medication (over the counter) before leaving the facility in the morning.

On 04/19/2022 at 10:30 a.m., the LPA conducted a records review. The records review revealed the following: On 11/09/2021, the day program staff noticed R1 was in the restroom crying and saying they were in pain. Staff asked R1 if they were in pain and R1 said, ‘Yes’. When the staff asked R1 if they wanted to go home, R1 said, ‘Yes’. At 9:00 a.m., the staff called the facility administrator to informed them of R1’s stomach pain and the administrator confirmed that they knew about the pain and stated that they gave R1 pain medication (over the counter) before leaving the facility in the morning. The staff told the administrator that they should take R1 to the emergency room because R1 stated they were in pain. The administrator stated that they thought that R1 was fabricating the pain to get attention. The day program staff reiterated that R1 was in pain and that R1 seemed ‘zoned out’ and not aware of what was happening.

On 11/10/2021, at 10:40 a.m., the day program staff conducted a follow-up call to find out how R1 was doing, due to R1 not attending the day program on this day. The facility administrator mentioned that R1 ’has been in some pain’, but has been taking medication for the pain, and that R1 was in their room relaxing.

On the evening of 11/10/2021, at approximately 11:45 p.m., S1 stated that they were getting ready for bed. They first went to use 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 R1, ‘was dead’. S1 stated that they checked for R1’s pulse and there was no pulse. Although S1 was trained in CPR, S1 did not initiate CPR. S1 did not call the paramedics until approximately thirty-five (35) minutes after R1 had passed. At that point, the paramedics did not ask the staff to perform CPR.

Continues on LIC 9099 C...

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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: 05/13/2022
NARRATIVE
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Based on the records review and interviews, the day program staff reported that R1 was seriously ill and should be taken to the emergency room, based on their observation. However, the facility staff did not follow that suggestion and allowed R1 to remain at home in pain for two more days, waiting for R1’s scheduled appointment with their physician. As a result, the information obtained reveals that the facility did not seek timely emergency medical attention for R1, which poses an immediate health and safety risk to residents in care. Therefore, the allegation that the ‘Facility did not seek resident timely emergency medical attention’ is deemed Substantiated at this time.

Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited. An immediate civil penalty of $500 is also assessed. The licensee was informed that a civil penalty might be assessed based on the Health and Safety Code 1569,49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).

Citations were issued. Exit interview conducted. Today's reports, and appeal rights were reviewed with Administrator Pacita Serrano over the phone. Facility representative signed the report. Copy of the report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/20/2022
Section Cited
CCR
8775(a)
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80075(a)Health Related Services-The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.
This requirement is not met as evidenced by:
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The Administrator agreed to do the following: Submit a Statement of Understanding, explaining the steps the facility will follow to avoid similar issues from happening again and to ensure compliance to Title 22 Regulations regarding emergency medical assistance. Due 5/20/2022.
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Based on the investigation, the licensee did not comply with the section cited above, as the facility failed to ensure that R1 received timely medical attention pertaining to R1's stomach pain, even though an outside party believed it was warranted, which poses an immediate health and safety risk to residents 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: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5