198602285-11-18-2020-28-AS-MVAO-BXFRNN-20210120121036

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602285
Report Date: 11/09/2020
Date Signed: 11/18/2020 08:46:40 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
03/16/2020 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20200316100318

FACILITY NAME:	SERENITY CARE HEALTH EVERGREEN		FACILITY NUMBER:	198602285
ADMINISTRATOR:	OGBECHIE, BIOSEH		FACILITY TYPE:	740
ADDRESS:	131 SEGOVIA AVENUE		TELEPHONE:	(626) 699-4609
CITY:	SAN GABRIEL	STATE: CA	ZIP CODE:	91775
CAPACITY:	6	CENSUS: 5	DATE:	11/09/2020
		UNANNOUNCED	TIME BEGAN:	01:55 PM
MET WITH:	Jaimelita Ramos - Lead Caregiver		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is not sanitary

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Mary Flores conducted a subsequent 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 Jaimelita Ramos, Lead Caregiver.

The investigation consisted of the following: On 3/25/20 LPA Miramontes conducted telephone interviews with two staff and two residents. Attempted a video call and requested copies of the following documents resident roster, staff roster, informational and emergency sheet for each resident, hospice face sheet for resident #1 and 3#. On 6/12/20 LPA Flores conducted a virtual tour of the facility observed, the kitchen, living room, four bedrooms, and 2 bathrooms and requested face sheet, hospice documents, physician report, Needs and Service Plan, Medication sheets for resident #1, #2, #3 (R1, R2,R3) and interviewed facility's representative. On 6/30/20 LPA interviewed Hospice Agency nurse. On 7/13/20 LPA received the requested documents via email. On 11/9/20 LPA Flores interviewed resident #2,#3,#4 (R2,R3,R4) and 1 staff.
(Continued 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2020

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 2

Control Number 28-AS-20200316100318

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: 11/09/2020

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

The investigation revealed the following: Regarding allegation facility is not sanitary; It is alleged that a water bottle with urine was observed, and bottle was just sitting there. It was also alleged that there were feces on the wall next to R1's bed as someone wiped his dirty fingers on the wall. During the investigation LPA conducted a tour of the facility which consisted of the kitchen, living room, 4 bedrooms, and 2 bathrooms. LPA observed clean walls throughout the facility, observed an empty and clean urinal in bedroom #2, bathrooms and bedrooms were clean, with no food, water bottles, or excrement observed around the facility.2 out of 2 staff revealed that R1 receives services from home health care, and R1, R2,R3 were under hospice care and home health services. 1 out 1 staff stated that facility staff provides immediate toileting care for residents due to their condition. Interviews with 1 out 3 residents revealed that staff maintain the facility clean as well as ensure to assist with changing right away. 2 out of 3 residents were unable to respond to interview questions due to cognitive condition. During interview with Hospice agency nurse, no concerns were revealed. It was stated that the facility is maintain cleaned as well as the residents. Nurse has not observed excrement in the walls, and or smell urine in the resident's bedrooms. Documents reviewed revealed residents are under hospice care and maintain home health care visits.

Based on LPA's interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation(s) are found Unsubstantiated.

Exit interview was conducted with Jaimelita Ramos via telephone, a copy of this report was email for signature to facility's representative Andrew Hasen.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 2