197609807-12-20-2022-31-AS-NMAN-CRNPRQ-20230509113308

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609807
Report Date: 12/20/2022
Date Signed: 12/20/2022 03:52:51 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., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/03/2022 and conducted by Evaluator Tihesha Smith

COMPLAINT CONTROL NUMBER: 31-AS-20221103153130

FACILITY NAME:	SERENITY PATHWAYS, INC		FACILITY NUMBER:	197609807
ADMINISTRATOR:	ISIKO, FAITH NASSALI		FACILITY TYPE:	735
ADDRESS:	10522 CEDROS AVE		TELEPHONE:	(818) 274-2692
CITY:	MISSION HILLS	STATE: CA	ZIP CODE:	91345
CAPACITY:	4	CENSUS: 3	DATE:	12/20/2022
		UNANNOUNCED	TIME BEGAN:	09:56 AM
MET WITH:	Bernard Isiko		TIME COMPLETED:	03:57 PM

ALLEGATION(S):

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Staff mishandled a client's medication while in care
Staff did not meet a client's diabetic needs while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tihesha conducted a complaint visit to this facility on 12/20/2022 at 9:56 AM. LPA was greeted by care staff who contacted the administrator and revealed will arrive shortly. LPA contacted administrator at approximately 10:45 am and was informed that is unable to come due to Covid-19 exposure and will have other staff, Kumbirai Zvaita to sign report as Program Director also is currently unavailable. Staff arrived at approximately 11:35 am. LPA conducted interview with staff from Approximately 11:50 am – 12:50 pm. Program Director arrived approximately 12:35 pm.

LPA Smith made an unannounced subsequent complaint visit to this facility on 12/12/2022. LPA Smith interviewed the Program Director from 11:48 AM-12:45 PM; reviewed Medication Administration Record (MAR), physician’s notes and client medications from 12:45 pm- 1:50 pm. LPA requested records relevant to the investigation from 1:50 pm- 2:18 pm.
During initial visit on 11/07/22, LPA conducted a physical plant tour to ensure there are no immediate
(Cont to 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

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 31-AS-20221103153130

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SERENITY PATHWAYS, INC	FACILITY NUMBER: 197609807
	VISIT DATE: 12/20/2022

NARRATIVE

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(Cont. from 9099)

health and safety issues at 10:35 am, interviewed Licensee from 10:50 AM- 11:20 AM
and requested copies of documents relevant to the investigation at 11:25 AM.

Staff mishandled a client's medication while in care

It was alleged that staff mishandled a clients’ medication while in care. LPA's interview with staff reveal that staff administers medication according to doctors’ directions and the medication record is completed immediately following any pills dispensed to the residents. On 12/12/2022, LPA Smith reviewed medication supply and medication records for three (03) out of three (03) residents. Resident #1’s (R1) medication for diabetes is noted as PRN or as needed. No discrepancies were noted during review.

Based on interviews, observation, and documentation there is insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Staff did not meet a client's diabetic needs while in care

It was alleged that staff are not meeting a client’s diabetic needs. Interviews with staff reveal that staff are providing meals that follow client’s diabetic dietary needs which do not include sugary foods or drinks. Interview with Staff #5 (S5) revealed that R1 diet was changed after diabetes diagnosis to include fish, vegetables and exclude carbohydrates and sugars. LPA reviewed food supply and found adequate food for diabetic menu to include an adequate supply of fresh vegetables and fish such as Tilapia. There is also a posted diabetic menu on the refrigerator for R1.

Based on interviews, observation, and documentation there is insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No deficiencies observed during this visit.

Exit interview conducted/Copy of report emailed

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC9099 (FAS) - (06/04)

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