197609921-9-17-2022-31-AS-MVAO-CLNVZQ-20221130155307

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609921
Report Date: 09/17/2022
Date Signed: 09/17/2022 03:41:43 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
02/10/2021 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:	09/17/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Errol Fernando		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

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Resident sustained a urinary tract infection while in care.
Staff did not seek medical attention in a timely manner.

INVESTIGATION FINDINGS:

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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.

---Resident sustained a urinary tract infection while in care.
It was alleged that Resident #1 (R1) sustained a bladder infection while in care. To investigate this allegation, on 08/27/2022 at 11:30 AM, LPA interviewed two (02) staff, on 08/27/2022 at 01:30 PM, LPA conducted a record review and, on 09/17/2022 at 10:30 AM - 11:30 AM, LPA interviewed with the facility’s Administrator and R1's responsible party. Interviews and record reviews revealed that although R1 sustained a bladder infection while in care, R1 was admitted to the facility with prior health conditions, most notably, recurring urinary tract infections. There is a lack of substantial evidence that the resident sustained the infection due to the neglect in care and supervision. Based on interviews and record review, there is not enough information to verify the allegation, therefore, the allegation is UNSUBSTANTIATED at this time.
(Cont. on LIC9099-C)

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: 09/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2022

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-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: 09/17/2022

NARRATIVE

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--- Staff did not seek medical attention in a timely manner.

It was alleged that staff did not seek medical attention timely. To investigate this allegation, on 08/27/2022 at 11:30 AM, LPA interviewed two (02) staff, on 08/27/2022 at 01:30 PM, LPA conducted a record review and, on 09/17/2022 at 10:30 – 11:30 AM, LPA interviewed the Administrator and R1’s responsible party. During interviews, the responsible party stated that R1 had bloody discharge and was unable to communicate with R1 effectively as R1 was in a mental state of confusion. In contrast, the Administrator stated that R1 did not have a change in mental state and was able to communicate with others very well but did agree that R1 had bloody discharge. Furthermore, interviews and record reviews revealed that although R1 had bloody discharge, R1 used a urinary catheter which can cause small bleeding as the catheter tube passes along the lining of the urethra. At this time, there is a lack of substantial evidence that there were changes in R1’s health condition prior to the responsible party seeking medical attention and receiving a diagnosis. Based on interviews and record review, 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: 09/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2022

LIC9099 (FAS) - (06/04)

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