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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609921
Report Date: 09/07/2022
Date Signed: 09/07/2022 02:54:08 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
07/21/2022 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20220721163345
FACILITY NAME:SERENITY SENIOR RETREATFACILITY NUMBER:
197609921
ADMINISTRATOR:PERERA, JILSKAFACILITY TYPE:
740
ADDRESS:26213 BEECHER LANETELEPHONE:
(661) 313-3030
CITY:STEVENSON RANCHSTATE: CAZIP CODE:
91381
CAPACITY:6CENSUS: 5DATE:
09/07/2022
UNANNOUNCEDTIME BEGAN:
11:04 AM
MET WITH:Eddie Provost - Co AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff are mistreating residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent visit to this facility to further investigate the above allegation. LPA met with staff Glenda Dulay who called the administrator Eddie Provost and explained the reason for the visit. Ms. Provost arrived twenty (20) minutes later.

LPA conducted physical plant tour at 11:15 AM, requested copy of facility documents relevant to the investigation at 11:45 AM and interviewed additional staff and residents between 12:10 PM to 2:00 PM.

Regarding the allegation that staff are mistreating residents, it was alleged that residents at the facility are being mistreated by the staff. LPA's interview with residents on 07/27/22 at around 1:20 PM and today at 12:30 PM revealed that all four (4) residents interviewed did not experience being mistreated by anyone at the facility. All four (4) residents interviewed revealed that the staff are respectful and take care of all of their care needs. LPA's interview with staff on 07/27/22 at around 1:45 PM and today at 1:00 PM, also revealed that all three (3) staff denied mistreating any resident nor witnessed any staff mistreating any resident. (continued on LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022
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 2
Control Number 31-AS-20220721163345
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 SENIOR RETREAT
FACILITY NUMBER: 197609921
VISIT DATE: 09/07/2022
NARRATIVE
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(continued from LIC 9099)

Based on the information gathered during this and prior visit, there is no information to support the allegation and therefore deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2