198602285-2-3-2022-28-AS-LHIS-CCQUM5-20220321154146

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602285
Report Date: 02/03/2022
Date Signed: 02/03/2022 11:48:53 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
01/28/2022 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220128121943

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: 3	DATE:	02/03/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Belen Taico, Caregiver		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Facility does not follow COVID-19 guidelines.
Facility does not provide residents sufficient lighting.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted an initial 10-Day complaint visit to investigate the above allegations.The purpose of the visit was discussed with Lead Caregiver Belen Taico. House Manager Robin Aquino was explained the purpose of the visit and interviewed telephonically.

The investigation consisted of: LPA toured the facility. Staff (S1-S3) and resident (R1) were interviewed. Residents Face Sheets, LIC 500 Personnel Report, and a copy of the COVID-19 Mitigation Plan were obtained. LPA requested a staff schedule for week of November 14, 2021 - November 20, 2021. However, House Manager was not able to provide it during today's visit.

Allegation: "Facility does not follow COVID-19 guidelines." It is alleged that on November 16, 2021 a visitor observed staff (S2) and female visitor, allegedly staff's sister, not wearing face masks. Staff (S2) informed the visitor that the reason for not wearing a mask is because it was eating at that time. The alleged staff's sister was observed entering the living room without a mask. Visitor was explained that the female visitor was using
*See LIC 9099C for report continuation.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022

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 28-AS-20220128121943

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/03/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/04/2022 Section Cited HSC 1569.50(a)(3)	1 2 3 4 5 6 7	The department may deny an application for a license or may suspend or revoke a license issued under this chapter upon any of the following grounds and in the manner provided in this chapter:(3) Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California.	1 2 3 4 5 6 7	Licensee shall ensure that facility is following California Dept of Public Health and CCLD requirements. Provide a written statement stating that facility staff were re-trained and will comply with CDSS requirements and regulations, and will maintain a safe and healthful environment for residents and staff.
	8 9 10 11 12 13 14	This requirement was not met by evidence of: On Nov. 16, 2021 one staff and one visitor were observed not wearing face coverings. The visitor was staff's sister, and was not eating when it was observed. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 02/10/2022 Section Cited CCR 87303(d)	1 2 3 4 5 6 7	Maintenance and Operation. There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility. This requirement was not met by evidence of:	1 2 3 4 5 6 7	Licensee shall ensure there is lamp in each bedroom. In addition, staff shall be trained regarding facility operational guidelines regarding lighting and dinner time routine. Submit picture proof of lamp installed in rooms 2 & 3, and submit a training log with training materials attached.
	8 9 10 11 12 13 14	Based on observation on November 16, 2021 all resident room lights were turned off by 4:19 PM. Today rooms 2 & 3 did not have lamps. Room 4 had lights off during today's visit. Resident prefers to have lights on at all time. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220128121943

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: 02/03/2022

NARRATIVE

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CONTINUATION of Allegation: " "Facility does not follow COVID-19 guidelines."

the restroom prior to entering the living room. Per current Department of Public Health guidelines all staff and visitors must wear masks while working.The facility's COVID-19 Mitigation Plan states "Visitors are required to wear face coverings." Staff (S2) stated that on November 16, 2021 a visitor entered the facility while the staff was eating. Therefore, was not wearing a mask. Staff (S2) denied that there was a female visitor, alleged "sister" on that day. Staff (S2) stated it was the only staff working at the time of the visit. House Manager stated that staff are allowed to have family/friends visit during their break times, but cannot stay longer than 30-40 minutes, and must wear masks at all times. All staff interviewed stated they are allowed to eat indoors, and do not have masks on while eating. Staff stated that when they take breaks outside they put a mask on before entering the house and wash their hands. Staff stated they are screening all visitors and require everyone to wear a mask. However, on November 16, 2021 at approximately 4:19 PM a visitor observed staff (S2) and staff's visitor (sister) not wearing masks. NOTE: The COVID-19 Mitigation Plan was not printed or accessible to facility staff during today's visit. House Manager emailed staff a copy and it was printed and placed in a binder.

Allegation: "Facility does not provide residents sufficient lighting." Based on information obtained and interviews conducted the findings indicate that on November 16, 2021 at approximately 4:19 PM a visitor observed all resident room lights were turned off and residents were in bed. Staff (S2) was on duty at the time of the visit and said the residents had gone to bed 20 minutes prior to the visitor's arrival. Staff stated that dinner time is between 3:45 PM - 5:00 PM, but are typically fed at 4:30 PM. Staff stated that residents are put to bed after dinner, unless they do not want to go to bed. Staff reported that at least two residents at the time of the incident did not like lights on in their room. Resident (R1) was interviewed today and stated it prefers to have lights on at all times. The resident's room overhead lighting was observed to be turned off during today's visit. During today's physical plant inspection overheard lighting was observed in all rooms, but two rooms (rooms 2 & 3) did not have lamps in the room to ensure the comfort and safety of residents in care.

Based on observations and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22.

Exit interview was conducted with House Manager Belen Taico. A copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022

LIC9099 (FAS) - (06/04)

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