197609888-2-16-2023-31-AS-NMAN-CUCLBU-20230803083718

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609888
Report Date: 02/16/2023
Date Signed: 02/16/2023 05:16:57 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
02/16/2023 and conducted by Evaluator Tihesha Smith

COMPLAINT CONTROL NUMBER: 31-AS-20230216113159

FACILITY NAME:	SERENITY MANOR LLC		FACILITY NUMBER:	197609888
ADMINISTRATOR:	WEISMAN, MICHELLE		FACILITY TYPE:	740
ADDRESS:	4934 SWINTON AVE		TELEPHONE:	(818) 386-8540
CITY:	ENCINO	STATE: CA	ZIP CODE:	91436
CAPACITY:	6	CENSUS: 6	DATE:	02/16/2023
		UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Michelle Weisman		TIME COMPLETED:	05:20 PM

ALLEGATION(S):

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Resident sustained injuries while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tihesha Smith made an unannounced complaint visit to this facility at to investigate the above allegation. LPA met with staff and disclosed the reason for the visit. The administrator was contacted and arrived later.

LPA conducted a physical plant tour at approximately at 1:00 pm to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. LPA did not observe any immediate health and safety issues during the visit.

LPA conducted interviews with two (2) staff members between approximately 1:20 pm – 1:55 pm, and additional parties relevant to the investigation between 12:40 pm – 3:15 pm. In addition, LPA requested copies of pertinent documents relevant to the investigation at 1:30 pm.
Resident sustained injuries while in care.
(Cont. to 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

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-20230216113159

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 MANOR LLC	FACILITY NUMBER: 197609888
	VISIT DATE: 02/16/2023

NARRATIVE

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(Cont. from 9099)

Concerns were expressed that resident sustained injury while in care specifically Resident #1 (R1) was alleged to have two (2) "gashes'' on her left cheek and a bruise to their right temple. According to information obtained through interviews staff revealed all residents are treated with care. Staff indicated R1 had scratched their cheek as blood was present in R1s fingernails. Staff also revealed R1 having older wooden bed and R1's nightstand was positioned next to bed thereby possibly causing temple injury. Per interviews: staff and additional parties agree to cause of injuries. In order to prevent any additional injuries staff cut down R1’s fingernails. R1's nightstand was moved further away from bed and new bed was ordered. LPA observed R1 at kitchen table scratching and picking small scratches/scabs on left cheek and scratching lips. LPA also inspected R1s room and observed nightstand positioned away from new bed and old wooden bed moved to facility storage.

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

Exit interview conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

LIC9099 (FAS) - (06/04)

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