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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608600
Report Date: 07/02/2024
Date Signed: 07/10/2024 10:56:42 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/26/2024 and conducted by Evaluator Leizl De La Cerra
COMPLAINT CONTROL NUMBER: 31-AS-20240626143208
FACILITY NAME:SERENE LIFE SENIOR CAREFACILITY NUMBER:
197608600
ADMINISTRATOR:SAMUEL C. TANFACILITY TYPE:
740
ADDRESS:11221 LULL STREETTELEPHONE:
(818) 308-6578
CITY:SUN VALLEYSTATE: CAZIP CODE:
91352
CAPACITY:6CENSUS: 6DATE:
07/02/2024
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Rima Abelian, Administrator/LicenseeTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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Facility is not adhering to their license
INVESTIGATION FINDINGS:
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Licensing Program Analysts LPA Leizl de la Cerra conducted an unannounced visit for the above noted allegation. LPA met with Facility Administrator/Licensee, Rima Abelian and explained the reason for the visit. It was reported that bedridden resident (R1) is in room #2 but room #2 is not approved for fire clearance for a bedridden resident. To investigate this allegation on 7/02/2024, LPA requested copies of facility documents relevant to the investigation at 1:30pm, records included but not limited to residents’ and staff roster, R1’s facility file and etc. LPA de la Cerra conducted a facility tour between 2:00pm and 2:45pm. Requested files were reviewed between 2:45pm and 3:15pm. Staff interview was initiated between 3:15pm and 4:15pm.

Continue to 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Leizl De La CerraTELEPHONE: (818) 454-0632
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024
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 31-AS-20240626143208
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SERENE LIFE SENIOR CARE
FACILITY NUMBER: 197608600
VISIT DATE: 07/02/2024
NARRATIVE
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A Review of R1’s physician report identified R1 as a bedridden resident. A review of facility approved Fire clearance completed on 02/05/2014,revealed that only room #3 is approved to retain bedridden resident. During facility inspection LPA de la Cerra observed bedridden resident R1 residing in the bedroom #2, which is not cleared bedridden fire clearance. Residents' roster also verified that R1 was residing in the bedroom #2. Furthermore, staff interview confirmed that R1 is bedridden resident receiving hospice care and acknowledged R1 is in a room that is not cleared to retain bedridden resident.

Based on inspection, observation, interviews and record reviews, there is sufficient information to support the allegation. Therefore, allegation is substantiated at this time. Per CA Code of Regulations, Title 22 Division 6, Chapter 8, the following deficiency was cited and recorded on LIC9099-D. Non-compliance with fire clearance is posing immediate health and safety hazard to residents in care. Therefore, an immediate Civil penalty of $500.00 was assessed at the time of this visit.
No other health and safety issues were observed at this time.

Exit interview conducted. Appeal rights were discussed, and a copy of the report will be given to administrator.

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Leizl De La CerraTELEPHONE: (818) 454-0632
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Citations on this Visit Report are Under Appeal!

Control Number 31-AS-20240626143208
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SERENE LIFE SENIOR CARE
FACILITY NUMBER: 197608600
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
07/03/2024
Section Cited
CCR
87202(a)(2)
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87202(a)(2) All facilities shall maintain a fire clearance approved by fire dept... Prior to accepting any of the following types of persons, licensee shall obtain an appropriate fire clearance approved by fire dept, (2)Bedridden persons.This requirement is not met as evidenced by

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Administrator stated that R1 will be transferred to the bedroom #3 by the end of the day. and within 24h will inform Licensing office in writing about R1’s relocation.
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The Licensee failed to follow Title 22 Regulations regarding approved fire clearance, by placing bedridden resident R1 to the room that had no bedridden fire clearance. This 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.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Leizl De La CerraTELEPHONE: (818) 454-0632
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3