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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602285
Report Date: 02/08/2024
Date Signed: 02/21/2024 03:08:08 PM

Substantiated


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
12/22/2021 and conducted by Evaluator Nune Margaryan
COMPLAINT CONTROL NUMBER: 28-AS-20211222130754
FACILITY NAME:SERENITY CARE HEALTH EVERGREENFACILITY NUMBER:
198602285
ADMINISTRATOR:OGBECHIE, BIOSEHFACILITY TYPE:
740
ADDRESS:131 SEGOVIA AVENUETELEPHONE:
(626) 699-4609
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY:0CENSUS: 0DATE:
02/08/2024
UNANNOUNCEDTIME BEGAN:
07:47 AM
MET WITH:TIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Uncleared Staff working at the facility
Staff uses substance during work at the facility
INVESTIGATION FINDINGS:
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Investigation consisted of the following: Initial visits conducted on 12/24/21 by LPA Gleen Trueman and 12/14/23 by LPA Nune Margaryan. At the time of visits facility was toured, food supplies for 2 days perishables, 7 days nonperishables and Emergency food supplies were observed. Staff and residents roster was requested, additional interviews were conducted.
The investigation for this complaint was conducted by Investigator Brian Slatic Badge #216.
During the course of this investigation: Investigations Branch conducted an investigation and found that an uncleared adult who lacked a criminal-record exemption was present at the facility. Through social-media pictures and by visiting the facility, the IB investigator was able to confirm that Contact #4 (C#4) had been present at the facility. The social-media pictures, at times, depict C#4 consuming alcohol at the facility.

Continued 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
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 4
Control Number 28-AS-20211222130754
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: 02/08/2024
NARRATIVE
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The IB investigator also did an unannounced visit and found C#4 at the facility on January 21, 2022. During the investigation, while the IB investigator was at the facility, IB saw C#4 at the facility. C#4 quickly went into the bathroom when IB first saw her. Another caregiver / staff, Contact #2 (C#2), first indicated that C#4 was at the facility. But when C#2 got a phone call, C#2 changed their story and said the person they thought was C#4 was actually Contact #6 (C#6), another caregiver. At the same visit, the IB investigator interviewed C#4, but C#4 pretended to be C#6. When the IB investigator asked C#4 (who was pretending to be C#6) for her date of birth, C#4 provided incorrect date. The IB investigator asked C#4 if they was C#4, and they said No. When the IB investigator showed C#4 their DMV photo, C#4 finally reluctantly admitted they was C#4. C#4 said they felt compelled to lie because C#2 lied. Investigator conducted a telephone interview with C#5. C#5 denied that C#4 was working at the Facility. Additional interviews conducted with C#6 and C#3. C#6 and C#6 stated that C#4 was regularly present and working in the facility.

Allegation: Uncleared Staff working at the facility. It was alleged that C#4 did not have a criminal record clearance and was working in the facility.

Photographs taken from social media show evidence that C#4 was regularly present and working in the facility. In addition, Investigator conducted an unannounced visit to the facility and found C#4 present and having contact with clients. Facility manager Contact #5 (C#5) denies allowing C#4 to “work under the table.” C#5 told investigator C#5 knew nothing about C#4 living or working in the facility.

Allegation: Staff uses substance during work at the facility. It was alleged that Staff members use substances including cocaine, marijuana, and alcohol during work at the facility.



Photographs taken from social media showed evidence consistent with alcoholic beverages in the facility and at least one staff member consuming an alcoholic beverage with C#4, an uncleared adult present in the facility. It could not be conclusively established that cocaine and marijuana were used in the facility. C#5 denies using any of these substances in the facility and denies knowing they are being used.

Based on observations and interviews which were conducted, record reviews the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Citations issued on the 9099D.

Facility closed on 08/23/2022 and the copy of this report was mailed out to last noted facility mailing address.

SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20211222130754
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: 02/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/08/2024
Section Cited
CCR
87355(e)(1)
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Criminal Record Clearance. (e)All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1)Obtain a California clearance or a criminal record exemption as required by the Department
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Facility was closed on 8/23/22
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This requirement has not been met as evidenced by: Based on interviews and observation, the licensee did not comply with the section cited, Staff (C#4) was working at the facility without criminal record clearance which poses a health and safety risk to the residents in care.
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Type A
02/08/2024
Section Cited
CCR
87468.2(a)(4)
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In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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Facility was closed on 8/23/22
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Based on interviews and observation, the licensee did not comply with the section cited, as a photo of an alcoholic beverage was taken in the facility and staff posted on social media they were drinking while at work which poses an immediate health and safety risk to the 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.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
12/22/2021 and conducted by Evaluator Nune Margaryan
COMPLAINT CONTROL NUMBER: 28-AS-20211222130754

FACILITY NAME:SERENITY CARE HEALTH EVERGREENFACILITY NUMBER:
198602285
ADMINISTRATOR:OGBECHIE, BIOSEHFACILITY TYPE:
740
ADDRESS:131 SEGOVIA AVENUETELEPHONE:
(626) 699-4609
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY:0CENSUS: 0DATE:
02/08/2024
UNANNOUNCEDTIME BEGAN:
07:47 AM
MET WITH:TIME COMPLETED:
10:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff allows unauthorized adults into the facility.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Investigation consisted of the following: Initial visits conducted on 12/24/21 by LPA Gleen Trueman and 12/14/23 by LPA Nune Margaryan. At the time of visits facility was toured, food supplies for 2 days perishables, 7 days nonperishables and Emergency food supplies were observed. Staff and residents roster was requested, interviews were conducted.
The investigation for this complaint was conducted by Investigator Brian Slatic Badge #216.
Alegation: Staff allows unauthorized adults into the facility. It was alleged that Contact #4 (C#4) allowed an unauthorized male into the facility at night.
Investigations Branch conducted an investigation and based on IB’s interviews with staff members, all staff members denied the allegation.
Based interviews conducted, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation ia Unsubstantiated.
Facility closed and the copy of this report was mailed out to last noted facility mailing address.



Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4