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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608975
Report Date: 04/21/2021
Date Signed: 04/21/2021 12:46:55 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/22/2020 and conducted by Evaluator Ashley Smith
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20200522093556
FACILITY NAME:MY SERENITY BOARD AND CAREFACILITY NUMBER:
197608975
ADMINISTRATOR:MASTOV, ELLAFACILITY TYPE:
740
ADDRESS:6658 CAPISTRANO AVETELEPHONE:
(323) 327-8662
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:6CENSUS: 6DATE:
04/21/2021
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Ella Mastov and Ariel MastovTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Resident fell resulting in a bruise while in care
Staff mishandling residents medication
Licensee does not provide staff training
Facility has converted the garage to living quarters without a permit or fire clearance
Uncleared staff providing care and supervision to residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith initiated a subsequent complaint investigation for the above allegations. Upon arrival, the LPA met with staff George Bat-Ochir who contacted Administrator Ella Mastov via phone. The LPA spoke with Ms. Mastov and informed them of the reason for the visit. Administrator Ariel Mastov arrived shortly after.

During the 6/1/2020 virtual visit, the LPA spoke with Administrator Ella Mastov 12:40am and requested documents. During today’s visit, the LPA conducted a physical plant tour at 9:35am, audited files at 9:55am, audited medications at 10:02am, and interviewed four staff between 9:43am – 11am.

Regarding the allegation: Resident fell resulting in a bruise while in care
It was alleged that due to lack of supervision, Resident #1 (R1) had fallen multiple times and attempts to ambulate without assistance, which has resulted in bruising.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021
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 31-AS-20200522093556
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: MY SERENITY BOARD AND CARE
FACILITY NUMBER: 197608975
VISIT DATE: 04/21/2021
NARRATIVE
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At the time of the allegation, it was disclosed that on 5/6/2020, R1 was pushed by Resident #2 (R2), which resulted in R1 falling and bruising their right arm. This incident took place in front of staff, yet staff were unable to intervene before R2 pushed R1. The facility self-reported this incident on 5/14/2021. Interviews revealed that R1 is able to ambulate on their own but requires standby assistance because R1 has an unsteady gait. In addition, interviews revealed that R1 attempts to ambulate without staff assistance, yet staff claim they are near R1 at all times to prevent falls. R1’s pre-placement appraisal, dated 2/20/2020, notes that R1 refuses to use their walker. Similar information is reflected in R1’s Needs and Services Plan, dated 2/22/2020, in which it is documented that R1 doesn’t like to get help when necessary, doesn’t want to use walker. Based on the information obtained, there is insufficient evidence to support the claim that due to lack of supervision, R1 fell and sustained a bruise. This allegation is deemed Unsubstantiated at this time.


Regarding the allegation: Staff mishandling residents medication
It was alleged that staff administered incorrect medication to a resident (name unknown). During today’s visit, the LPA conducted a medication audit at 10:02am. The LPA was unable to find evidence that there were any recent medication errors or that medication was incorrectly given to another resident. The LPA audited the facility Special Incident Reports (SIRs) and did not find evidence that the facility self-reported a medication error. Staff denied claims that any medication errors had taken place. Based on the information obtained, there is insufficient evidence to support the claim that staff mishandled medication. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Licensee does not provide staff training
It was alleged that the staff did not receive training on how to work with residents diagnosed with dementia and alleged that staff were not trained to administer medications. During today’s visit, the LPA audited two out of four staff files (S2, S2) at 9:55am. The LPA observed the files to be complete, with all required documents. The LPA observed that the two staff were hired within the last year, and the LPA observed that the staff received the initial forty hours of training as required per regulation. In addition, the LPA observed the correct number of dementia hours required per regulation. Interviews with staff confirmed that they have received training within the past 12 months. The LPA also observed that residents received medication training within the past 12 months. Based on the information obtained, there is insufficient evidence to support the claim that the licensee does not provide staff training. This allegation is deemed Unsubstantiated at this time.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20200522093556
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: MY SERENITY BOARD AND CARE
FACILITY NUMBER: 197608975
VISIT DATE: 04/21/2021
NARRATIVE
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Regarding the allegation: Facility has converted the garage to living quarters without a permit/clearance
It was alleged that staff were sleeping in the garage. The LPA audited the facility file and identified that the garage was converted into a staff office. This was also confirmed and documented during the pre-licensing inspection conducted on 2/26/2016. During today’s visit, the LPA conducted a physical plant tour at 9:35am. At 9:41am, the LPA observed the garage/office, and observed office equipment and some old resident furniture. The LPA did not observe a bed or any other furniture to indicate that staff were sleeping in the garage/office space at the time of observation. At 9:44am, the LPA observed the dedicated staff room, where the live-in staff sleep. Staff denied that they ever slept in the office and confirmed that they slept in their designated room. Based on the information obtained, there is insufficient evidence to support the claim that the garage was converted to living quarters. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: uncleared staff providing care and supervision to residents
It was alleged that Staff #1 (S1) was not cleared to work at the facility. The LPA audited the facility clearance list and found S1 to be cleared and associated. After further review of the online caregiver background check system, it revealed that S1 had been associated to the facility since 6/10/2019, which was before this complaint was filed on 5/22/2020. During today’s visit, the LPA verified that the current staff working at this facility are cleared and associated. Based on the information obtained, there is insufficient evidence to support the claim that uncleared staff were providing care to residents at this facility. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited. Exit interview conducted. The LPA called Ms. Mastov and explained the findings. Mr. Mastov signed the report. Report emailed to the licensee.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/22/2020 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 31-AS-20200522093556

FACILITY NAME:MY SERENITY BOARD AND CAREFACILITY NUMBER:
197608975
ADMINISTRATOR:MASTOV, ELLAFACILITY TYPE:
740
ADDRESS:6658 CAPISTRANO AVETELEPHONE:
(323) 327-8662
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:6CENSUS: 6DATE:
04/21/2021
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Ella Mastov and Ariel MastovTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility living room has bed bugs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith initiated a subsequent complaint investigation for the above allegation. The LPA initially met with George Bat-Ochir who contacted Administrator Ella Mastov via phone. Administrator Ariel Mastov arrived shortly after. During the 6/1/2020 visit, the LPA spoke with staff at 12:40am and requested documents. During today’s visit, the LPA conducted a tour at 9:35am, audited files at 9:55am, audited medications at 10:02am, and interviewed staff between 9:43am – 11am.

Regarding the allegation, it was alleged that there were bed bugs in the living room. An interview with the Administrator confirmed that the facility had bed bugs and an issue with roaches, but a pest control company treat the facility. Documentation confirmed that the living room and one bedroom was treated in March 2020, and a subsequent visit in April 2020 determied that there was no presence of bed bugs. Based on the information, there is sufficient evidence to support the claim that the facility living room had bed bugs. This allegation is deemed Substantiated at this time. Exit interview conducted, deficiencies cited (see 9099-D). Signatures obtained. A copy of the report and appeal rights were provided via email.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20200522093556
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: MY SERENITY BOARD AND CARE
FACILITY NUMBER: 197608975
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/21/2021
Section Cited
CCR
87303(a)
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87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by:
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The Administrator has agreed to do the following:
1. POC cleared at this time. The community treated the pest problem at the time the issue was present.
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Based on interviews and records review, the licensee did not comply with the section cited above, as the facility had an issue with pests, which poses a potential 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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5