197609921-2-1-2023-31-AS-NMAN-CPRVST-20230309154200

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609921
Report Date: 02/01/2023
Date Signed: 02/01/2023 02:31:13 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
01/17/2023 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20230117093943

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: 4	DATE:	02/01/2023
		UNANNOUNCED	TIME BEGAN:	01:39 PM
MET WITH:	Errol Fernando		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff leave residents unattended.
Staff yells at residents.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to investigate the above allegations. LPA met with the administrator, Errol Fernando, and discussed the reason for the visit.

--- Staff leave residents unattended.

It was alleged that staff leave the residents unsupervised. To investigate the allegation, on 01/17/2022, LPA conducted a physical plant tour at around 3:10 PM, interviewed three (03) staff and two (02) out of four (04) residents between 3:40 PM to 4:40 PM. On 01/18/2022 at around 3:00pm, LPA interviewed the Reporting Party. On 02/01/2022 at 1:45 PM, LPA interviewed two (02) additional staff. During the physical plant tour, LPA observed three staff present in the facility. During interviews with Staff #1 (S1), Staff #2 (S2), Staff #3 (S3), Staff #4 (S4) and Staff #5 (S5), they all stated that they do not leave residents unsupervised.
(cont. on LIC 9099-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: 02/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

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-20230117093943

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: 02/01/2023

NARRATIVE

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During interviews with residents, Resident #1 (R1) stated that staff do not leave residents unattended, Resident #2 (R2) was incoherent and LPA was unable to interview Residents #3 (R3) and #4 (R4). During an interview with the Reporting Party (RP), they stated that they don't know anything and hung up the phone. Subsequently, LPA made several attempts to reach the RP but to no avail. Based on observations and interviews, there is not enough information to verify the allegation, therefore, the allegation is unsubstantiated at this time.

--- Staff yells at residents.

It was alleged that staff yells at residents. To investigate the allegation, on 01/17/2022, LPA conducted a physical plant tour at around 3:10 PM, interviewed three (03) staff and two (02) out of four (04) residents between 3:40 PM to 4:40 PM. On 01/18/2022 at around 3:00pm, LPA interviewed the Reporting Party. On 02/01/2022 at 1:45 PM, LPA interviewed two (02) additional staff. During interviews with S1, S2, S3, S4 and S5, they all stated that they do not yell at residents. During interviews with residents, R1 stated that staff do not yell at residents, R2 was incoherent and LPA was unable to interview R3 and R4. During an interview with the Reporting Party (RP), they stated that they don't know anything and hung up the phone. Subsequently, LPA made several attempts to reach the RP but to no avail. 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 noted 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: 02/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

LIC9099 (FAS) - (06/04)

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