197609921-11-7-2022-31-AS-MVAO-CLNVZR-20221130155308

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609921
Report Date: 08/27/2022
Date Signed: 11/07/2022 11:06:42 AM

Substantiated

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
02/10/2021 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20210210133214

FACILITY NAME:	SERENITY SENIOR RETREAT		FACILITY NUMBER:	197609921
ADMINISTRATOR:	PERERA, JILSKA		FACILITY TYPE:	740
ADDRESS:	26213 BEECHER LANE		TELEPHONE:	(661) 313-3030
CITY:	STEVENSON RANCH	STATE: CA	ZIP CODE:	91381
CAPACITY:	6	CENSUS: 5	DATE:	08/27/2022
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Glenda Dulay		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff not properly reporting an incident regarding a resident.
Staff do not communicate with authorized representative regarding the change of resident's health conditions.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility. LPA met with Errol Fernando and explained the reason for the visit.
---Staff not properly reporting an incident regarding a resident
---Staff do not communicate with authorized representative regarding the change of resident's health conditions.
It was alleged that facility did not report an incident involving Resident #1 (R1). To investigate the above allegations, on 08/25/22 at 10:00AM, LPA reviewed facility’s file and, at 01:30PM, LPA reviewed the department’s records. On 09/17/22 at 10:30AM, LPA interviewed the administrator, Errol Fernando. Interviews and record review revealed that the facility did not submit an incident report after learning about R1’s change in health condition, the results from the doctor's visit and that the responsible party was not notified. Based on interviews and record reviews, the allegation is substantiated at this time. Pursuant to Title 22 Div.6 Ch.8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC9099-D): Exit interview was conducted, no health and safety hazards at this time. A copy of report was issued. (Cont on LIC9099-A)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2022

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 5

Control Number 31-AS-20210210133214

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/27/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/31/2022 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency...:(1) A written report shall be submitted to the licensing agency of the occurrence of...(D) any incident which threatens the welfare, safety or health of any resident... This requirement is not met	1 2 3 4 5 6 7	The Administrator will review Section 87211(a)(1)(D) and will inform in writing explaining how they will assure to follow Title 22 Regulations with regards to following reporting procedures.
	8 9 10 11 12 13 14	as evidenced by: Based on interviews & record reviews, the licensee did not comply with the section cited above as the facility did not notify the responsible party and send an incident report to the Dept. which poses a potential health & safety risk & violation of personal rights to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2022

LIC9099 (FAS) - (06/04)

Page: 2 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, 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
02/10/2021 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20210210133214

FACILITY NAME:	SERENITY SENIOR RETREAT		FACILITY NUMBER:	197609921
ADMINISTRATOR:	PERERA, JILSKA		FACILITY TYPE:	740
ADDRESS:	26213 BEECHER LANE		TELEPHONE:	(661) 313-3030
CITY:	STEVENSON RANCH	STATE: CA	ZIP CODE:	91381
CAPACITY:	6	CENSUS: 5	DATE:	08/27/2022
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Glenda Dulay		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff is not providing proper care and supervision to a resident.
Staff are not following a resident's medical orders.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility. LPA met with Glenda Dulay and explained the reason for the visit. The Administrator designated Glenda Dulay as the responsible staff member to sign and accept this report.

--- Staff is not providing proper care and supervision to a resident
It was alleged that resident has not been getting proper care at the board and care. To investigate this allegation, on 08/27/2022, LPA made observations during a physical plant tour at 10:30 AM and LPA conducted interviews with two (02) staff and five (05) out of five (05) residents from 11:30 AM – 01:15 PM. LPA’s observations revealed that staff are responding to residents’ needs, staff were observed to be checking on residents frequently, residents were clean and well-groomed and observed food and medication services being provided. Furthermore, interviews with residents revealed that they are well cared for and satisfied with the facility’s services, supervision and response times.
(Cont. on LIC 9099-A)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 31-AS-20210210133214

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: 08/27/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Based on observations and interviews, there is not enough information to verify the allegation, therefore, the allegation is UNSUBSTANTIATED at this time.

---Staff are not following a resident's medical orders.
It was alleged that staff would not take the resident’s blood pressure before administering medications. To investigate this allegation, on 08/27/2022, LPA conducted interviews with two (02) staff and five (05) out of five (05) residents from 11:30 AM – 01:15 PM. Interviews revealed that staff take the blood pressure of each resident prior to administering medication and that they do not refuse blood pressure measurement requests made by resident. Based on observations and interviews, there is not enough information to verify the allegation, therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards observed during the visit. Exit interview conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 5