198602285-8-5-2020-28-AS-MVAO-BS7MG9-20200805093532

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602285
Report Date: 07/29/2020
Date Signed: 08/05/2020 08:35:23 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/07/2019 and conducted by Evaluator David Sicairos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20191107094732

FACILITY NAME:	SERENITY CARE HEALTH EVERGREEN		FACILITY NUMBER:	198602285
ADMINISTRATOR:	OGBECHIE, BIOSEH		FACILITY TYPE:	740
ADDRESS:	131 SEGOVIA AVENUE		TELEPHONE:	(213) 444-6271
CITY:	SAN GABRIEL	STATE: CA	ZIP CODE:	91775
CAPACITY:	6	CENSUS: 5	DATE:	07/29/2020
		UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Andrew Hasan		TIME COMPLETED:	10:40 AM

ALLEGATION(S):

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Facility failed to safeguard resident's personal belonging while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Sicairos initiated a complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Administrator Andrew Hasan.

The investigation consisted of the following: during the initial visit conducted on 11/15/19, LPA obtained copies of Resident and Staff Rosters. LPA also obtained copies of Former Resident #1's (R1) Identification and Emergency Information Sheet, Physician's Report dated 07/11/18, Preplacement Appraisal, Resident Appraisal, Inventory List, and Certified Home Health Aide Assignment. LPA also interviewed the Administrator and Staff #1 (S1). LPA was unable to interview R1 as R1 passed away on 08/27/18. LPA interviewed Detective Gaona with the San Gabriel Police Department Investigations Unit on 06/30/20. LPA attempted to interview 2 employees from St. Liz Hospice on various occasions, however calls were not returned. LPA also communicated via email with R1's family members during course of investigation.
(CONTINUED ON 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2020

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 28-AS-20191107094732

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SERENITY CARE HEALTH EVERGREEN	FACILITY NUMBER: 198602285
	VISIT DATE: 07/29/2020

NARRATIVE

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The investigation revealed the following: in regards to the allegation, "facility failed to safeguard resident's personal belongings while in care", on 08/27/18 R1 was receiving hospice care services. It is alleged that one of the hospice care attendants observed a ring on R1's ring finger during the bath that was given on that day. At 4pm the end of life nurse took over the shift until R1's death at 11:25pm. R1's daughter was notified via phone call of the passing at which time R1's daughter asked the end of life nurse to remove the ring off the ring finger before the coroner arrived. End of life nurse saw that there was no longer any ring on the finger, but saw indentations on the finger showing there had been a ring recently there that could have been potentially removed. The police was also alerted to the alleged theft. Based on interviews conducted with facility staff, staff interviewed denied ever seeing a ring on R1's finger while R1 was a resident of the facility. LPA attempted numerous times to interview the two hospice care attendants that were present at the facility on 08/27/18, however calls were not returned. LPA obtained a copy of R1's "Personal Property Release" form indicating that R1 and/or responsible party agreed that no valuables will be allowed to be stored or kept in the facility which is signed by R1's responsible party dated 07/11/18. Investigator Gaona with The San Gabriel Police Department indicated via telephone interview that their Department investigation was officially closed out with "no findings" in regards to the possible suspect of the alleged theft. Therefore, based on information obtained throughout the investigation there was no evidence found indicating that the facility failed to safeguard R1's personal belongings.

Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Telephonic exit interview held, and a copy of this report was emailed to Administrator for signature.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2020

LIC9099 (FAS) - (06/04)

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