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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602870
Report Date: 12/19/2022
Date Signed: 12/19/2022 04:28:45 PM


Document Has Been Signed on 12/19/2022 04:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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



FACILITY NAME:SERENTO CASAFACILITY NUMBER:
198602870
ADMINISTRATOR:SARAH SESAYFACILITY TYPE:
741
ADDRESS:1740 SAN DIMAS AVENUETELEPHONE:
(909) 394-0304
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:131CENSUS: 60DATE:
12/19/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Steven Fairchild- AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit to the facility for the purpose of citing deficiencies. LPA Maldonado met with the administrator Steven Fairchild and explained the purpose for the visit.

While conducting a tour of the physical plant with Administrator Steven Fairchild, LPA Maldonado found that the signal system in resident restrooms of each room in the Memory Care Unit of the facility, are not operating. After inquiring with Staff# 1 (S1) on the reason why the signal systems are not working, it was discovered that they were disabled due to resident behaviors, only in the memory care unit. Memory care residents were pulling the cord of the call system without requiring assistance. LPA and Steven observed the signal system in room# 163 by pulling on the cord to initiate a call, and after 8 minutes of waiting, staff never arrived. Steven went to check with staff to see if they received a page or notification regarding the signal system in the room and staff informed Steven that no notification was received. S2 then inquired with the corporate office, who informed S2 of the signal system being disabled.

During today's visit, deficiencies were observed and will be cited on LIC809-D.

An exit interview was conducted with Administrator Steven Fairchild and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/19/2022 04:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: SERENTO CASA
FACILITY NUMBER: 198602870

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/09/2023
Section Cited

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87303 Maintenance and Operation
(i) Facilities shall have signal systems which...meet the following criteria:
(1) All facilities licensed for 16 or more...having separate floors... shall have a signal system which shall:(A)Operate from each resident's living unit.
Thie requirement was not met as evidenced by:
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The administrator will contact the signal system company to enable the system in the all the rooms in the memory care unit and creating a plan to keep residents from pulling the signal system cord when they don't require asistance. Plan and receipt for service from signal company sent to LPA by POC due date.
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Based on interviews and observations, the licensee failed to have an operating signal system in each resident's living unit, which poses a potential Health, Safety, and Personal Rights risk to persons 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: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2022
LIC809 (FAS) - (06/04)
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