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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320433
Report Date: 04/24/2026
Date Signed: 04/24/2026 02:07:30 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/05/2025 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20250205101344
FACILITY NAME:SERENITY SENIOR VILLAGEFACILITY NUMBER:
198320433
ADMINISTRATOR:SABINA NAYBERGFACILITY TYPE:
740
ADDRESS:2100 SOUTH WESTERN AVENUETELEPHONE:
(310) 548-0625
CITY:SAN PEDROSTATE: CAZIP CODE:
90732
CAPACITY:86CENSUS: 77DATE:
04/24/2026
UNANNOUNCEDTIME BEGAN:
01:02 PM
MET WITH:MARIA GALVANTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff did not provide timely medical care.
Resident sustained a serious injury while in care
Questionable death
INVESTIGATION FINDINGS:
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On 04/24/2026 the Community Care Licensing Division (CCLD) staff conducted a subsequent complaint investigation at Oceanview Living of San Pedro to deliver the investigation findings for the allegations listed above. This facility was named Serenity Senior Village during the complaint investigation, the facility name changed as of 05/01/2025. CCLD staff met with administrator Maria Galvan, and the purpose of the visit was explained.
The investigation consisted of the following: CCLD staff interviewed residents (R2-R5), Staff (S1-S10) and witness (W1). CCLD staff obtained and reviewed the following records: R1’s Physician’s Report (dated 08/07/2023, R1’s Medical Assessment (dated 06/26/2024). Incident Facility reports (dated 12/13/2024, 01/20/2025), Los Angeles Fire Department’s emergency response records dated 01/20/2025, R1’s Hospital Medical Records, and R1’s Death Certificate dated 02/08/2025.
The investigation revealed the following:
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2026
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 7
Control Number 11-AS-20250205101344
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SERENITY SENIOR VILLAGE
FACILITY NUMBER: 198320433
VISIT DATE: 04/24/2026
NARRATIVE
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Regarding the allegation: “Staff did not provide timely medical care. This complaint alleged that staff did not seek timely medical care for R1 who was in pain after an unwitnessed fall. Record reviews revealed the following: R1’s Physician Report (dated 08/07/2023) indicates that R1 was diagnosed with mild cognitive impairment, was non-ambulatory due to physical condition and requires a walker. The facility’s incident report indicates that on 01/20/2025 at 11:45 a.m., R1 was observed screaming in pain after an unwitnessed fall. Staff assessed R1, and that 911 was not called. The Los Angeles Fire Department emergency response records indicate that first responders arrived at the facility at 5:02p.m. on 01/20/2025. Hospital medical records indicate that on 01/20/2025 at 5:29 p.m. R1 arrived and was diagnosed with a Fractured Back, Urinary Tract Infection and Brain Bleed. Interviews revealed the following: On 01/20/2025 around 11:30 am S6 reported hearing R1 screams for help from R1’s room. S6 informed S7 of R1’s fall, S7 evaluated R1 and noted complaints of pain to R1’s back, S7 gave R1 Tylenol and staff lifted R1 from the floor and placed R1 on the wheelchair. At around 2:00 p.m. S8 called W1 to report that R1 was in pain and that the pain increased. On 01/20/2025 at around 4:30 pm W1 found R1 screaming in pain and asked staff to call 911. It took approximately five and a half (5 ½) hours for R1 to get medical attention. Based on the records review and interviews, the preponderance of evidence standard has been met. Therefore, the allegation that “staff did not provide timely medical care” is found to be SUBSTANTIATED.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 11-AS-20250205101344
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SERENITY SENIOR VILLAGE
FACILITY NUMBER: 198320433
VISIT DATE: 04/24/2026
NARRATIVE
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Regarding the Allegation: Resident sustained a serious injury while in care. This complaint alleged that R1 sustained serious injuries while in care. Record reviews revealed the following: R1’s Physician Report (dated 08/07/2023) indicates that R1 was diagnosed with mild cognitive impairment, was non-ambulatory and requires a walker. The incident reports dated 12/13/2024 indicate that on 12/13/2024, R1 had unwitnessed fall, and R1’s doctor ordered R1 to be taken to the hospital. The incident reports dated 01/20/2025 indicate that 0n 01/20/2025, R1 had a second unwitnessed fall. On 01/20/2025 Hospital medical records indicate that R1was diagnosed with a Fractured Back, Urinary Tract Infection and Brain Bleed. Interviews revealed the following: On 12/13/2024 after hospitalization following an unwitnessed fall, R1 was not assessed for fall risks, and a fall‑prevention plan was not developed. On 01/20/2025 at 11:30 a.m. S6 heard a loud commotion and screams from R1’s room. S6 was concerned about R1 back as R1 states that their back hurt. S6 informed S7 of R1’s fall and S7 evaluated R1 and noted complaints of pain to R1’s back. S7 gave R1 Tylenol and did not call 911. W1 indicates that R1 was transported to the hospital only after W1 told staff to call 911. On 01/20/2025 at 4:30 pm W1 found R1 screaming in pain and asked staff to call 911. Based on interviews and record reviews conducted by CCLD staff for R1 the preponderance of evidence standard has been met. Therefore, the allegation that “Resident sustained a serious injury while in care” is found to be SUBSTANTIATED.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 11-AS-20250205101344
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SERENITY SENIOR VILLAGE
FACILITY NUMBER: 198320433
VISIT DATE: 04/24/2026
NARRATIVE
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Regarding the Allegation: Questionable death. This complaint alleged that resident sustained a questionable death, due to staff’s failure to reassess and implement fall interventions after R1 fall on 12/13/2024 and staff’s failure to provide timely medical care after R1s fall on 01/20/2025. Record reviews revealed the following: The facility incident report dated (01/20/2025) approximately 11:30 am indicates that R1 had an unwitnessed fall and facility staff did not call 911 or transport R1 to the hospital. The Hospital records dated 01/20/2025 indicate that R1 was hospitalized after R1’s falls while at the facility on 12/13/2024 and on 01/20/2025. On 01/20/2025 R1 was diagnosed with Fractured Back, Urinary Tract Infection and Brain Bleed. On 01/31/2025 hospital records indicate that R1 died in the hospital, R1’s primary cause of death was listed as Acute Subdural Hematoma, which is a collection of blood under the skull's outer lining (dura), caused by severe head trauma, leading to rapid pressure on the brain. R1’s Death Certificate dated 02/05/2025 indicates Hemorrhagic Storke or bleeding inside the brain as cause of death. Interviews revealed the following: On 01/20/2025 around 11:30 am S6 reported hearing R1 screams for help from R1’s room. S6 informed S7 of R1’s fall, S7 evaluated R1 and noted complaints of pain to R1’s back, S7 gave R1 Tylenol and staff lifted R1 from the floor and placed R1 on the wheelchair. At around 2:00 p.m. S8 called W1 to report that R1 was in pain and that the pain increased. On 01/20/2025 at around 4:30 pm W1 found R1 screaming in pain and asked staff to call 911. Based on the reviewed records and interviews conducted, the preponderance of evidence standard has been met. Therefore, the allegation "Questionable death” is found to be SUBSTANTIATED.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 11-AS-20250205101344
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SERENITY SENIOR VILLAGE
FACILITY NUMBER: 198320433
VISIT DATE: 04/24/2026
NARRATIVE
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California Code of Regulations, Title 22, Division 6, Chapter 8 is cited on the attached LIC 9099D. An immediate civil penalty is being assessed please see LIC421IM.

At this time, an additional civil penalty determination is pending in reference to Health & Safety Code 1569.49(e) For a violation that the department determines resulted in the death of a resident. “

An exit interview was conducted, and a copy of the Complaint Report and Appeal Rights was provided to Administrator Maria Galvan.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 11-AS-20250205101344
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SERENITY SENIOR VILLAGE
FACILITY NUMBER: 198320433
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/30/2026
Section Cited
CCR
87465(g)
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87465 Incidental Medical and Dental Care: (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidence by:
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The administrator agreed to provide additional training to staff on seeking timely medical assistance for residents in care, proof of correction will be submitted to jose.calderon@dss.ca.gov.
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Based on records and interviews conducted the licensee did not ensure that staff immediately call 911 on 01/20/2025, staff did not immediately call 911 for R1 who was complaining of pain, this posed an immediate health, safety and personal risk to residents in care.
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Type A
04/30/2026
Section Cited
CCR
87463(a-b)
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87463 Reappraisals (a)The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. (b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. This requirement was not met as evidence by.
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The administrator agreed to create a plan to ensure that reappraisals are conducted for residents after falls resulting to hospitalizations, proof of correction will be submitted to jose.calderon@dss.ca.gov.
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Based on records review and interviews conducted, the licensee did not ensure that staff did a reappraisal of R1, after an unwitnessed fall that resulted in hospitalization on 12/13/2024. This poses an immediate health, safety and personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 11-AS-20250205101344
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SERENITY SENIOR VILLAGE
FACILITY NUMBER: 198320433
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/30/2026
Section Cited
CCR
87466
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87466 Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gain or losses or deterioration of mental ability or physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person. This requirement was not met as evidence by:
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The administrator agreed to create a plan that includes documenting all changes in residents’ physical, mental, emotional, and social functioning, ensuring timely notification to physicians and responsible persons, and implementing a fall‑prevention assessment. And that staff will be provided with training on the said plan within 10-days, and proof of correction will be submitted to jose.calderon@dss.ca.gov.
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Based on records and interviews conducted, the licensee did not ensure appropriate assistance after R1’s initial fall on 12/13/2024. No fall prevention plan or intervention was implemented, resulting in a second fall on 01/20/2025 that caused serious injuries that led to R1’s death. This posed an immediate health, safety and personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 7