198602870-12-19-2022-28-AS-MVAO-CN6UYZ-20230117150046

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602870
Report Date: 12/19/2022
Date Signed: 12/19/2022 04:24:24 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
12/12/2022 and conducted by Evaluator Valeria Maldonado

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221212113149

FACILITY NAME:	SERENTO CASA		FACILITY NUMBER:	198602870
ADMINISTRATOR:	SARAH SESAY		FACILITY TYPE:	741
ADDRESS:	1740 SAN DIMAS AVENUE		TELEPHONE:	(909) 394-0304
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	131	CENSUS: 60	DATE:	12/19/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Steven Fairchild- Administrator		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Staff do not respond to resident's call light in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) V. Maldonado made an unannounced complaint visit at the facility for the purpose of investigating the above-mentioned allegation. LPA Maldonado met with Administrator Steven Fairchild and the purpose for the visit was explained.

During today's visit, LPA Maldonado obtained a copy of the resident/staff roster and a copy of the "COVID-19 Practices" in-service training material along the sign-in sheet. LPA also conducted a tour of the physical plant with Administrator Steven and interviewed Residents# 3-6 (R3-R6) and Staff# 1-4 (S1-S4).

The investigation revealed the following:

(Report Continued on LIC9099-C...)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 28-AS-20221212113149

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: SERENTO CASA	FACILITY NUMBER: 198602870
	VISIT DATE: 12/19/2022

NARRATIVE

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Regarding allegation: Staff do not respond to resident's call light in a timely manner.
It is alleged that Resident# 1 (R1) is experiencing long wait times to receive care from staff, when the call light is pressed- R1 is not assisted in a timely manner. During interviews conducted with S1-S4, (3) of (3) staff admit that recently, a concern was brought up by the family of a Resident# 2 (R2) regarding the call light from R1's pendant was not being answered timely. S1 states a meeting was arranged with R2's family and it was discussed that staff would be reminded to attend to the calls of the pendants immediately. (4) of (7) residents stated they had no issues with receiving timely assistance from staff when the call pendants were used. (3) of (7) residents stated they have never used the call light from their bathroom and were not sure when it could be used. LPA observed (5) random resident's rooms and discovered that a call button was also located inside each resident's bathroom that is in their private room- (1) of the call lights being in the Memory Care Unit and (4) in the assisted living side. LPA tested the call buttons and discovered that in (2) of the (4) rooms in the assisted living side, it took staff to arrive to the room between 9-15 minutes. Staff arrived within 1 minute in the other (2) rooms, and in the (1) room located in the memory care unit, staff did not arrive. After 8 minutes of waiting, the administrator went to check with staff, and discovered that a page was not received for the call. It was later discovered that S4 obtained information from the corporate office indicating that the call buttons in the residents rooms of the memory care unit were disabled due to resident's behaviors resulting in pulling the cord of the call light often, without requiring assistance.

Based on interviews conducted, LPA observations, and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found to be Substantiated. The deficiencies are being cited on the attached LIC-9099D.

An exit interview was conducted with Administrator Steven Fairchild and a copy of the report and appeal rights was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
12/12/2022 and conducted by Evaluator Valeria Maldonado

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221212113149

FACILITY NAME:	SERENTO CASA		FACILITY NUMBER:	198602870
ADMINISTRATOR:	SARAH SESAY		FACILITY TYPE:	741
ADDRESS:	1740 SAN DIMAS AVENUE		TELEPHONE:	(909) 394-0304
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	131	CENSUS: 60	DATE:	12/19/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Steven Fairchild- Administrator		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Staff are not following COVID-19 protocols.
Staff are not wearing masks.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 28-AS-20221212113149

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: SERENTO CASA	FACILITY NUMBER: 198602870
	VISIT DATE: 12/19/2022

NARRATIVE

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Regarding allegation: Staff are not following COVID-19 protocols.
It is alleged that residents who tested positive for COVID-19 and were in isolation in their private rooms, had their room doors left open by care staff. It is also alleged that staff are not using Personal Protective Equipment (PPE) properly, are cross contaminating by disposing PPE in inadequate trash bins, and that food trays for COVID positive residents are placed alongside the meal trays for other residents that need to be delivered. Based on interviews conducted with S1-S4, (4) of (4) staff denied the allegations and stated the facility is following the mitigation plan. S1-S3 stated that the local Department of Public Health (DPH) recently visited the facility regarding a COVID-19 outbreak and the assigned DPH nurse did not have any concerns regarding their infection control practices. LPA spoke to DPH nurse and confirmed the information provided by S1-S3. Based on interviews conducted with R3-R7, (4) of (7) residents stated to not witness staff not following COVID-19. During a tour of the physical plant, LPA observed all floors to have hand sanitizer readily available, restrooms were stocked with liquid soap and paper towels for hand washing, LPA was screened upon entry, visitors were observed to be wearing face masks and were screened upon entry, all staff were observed to be wearing proper face masks, and kitchen staff were observed to be wearing gloves while handling food plates.

Regarding allegation: Staff are not wearing masks.
It is alleged that staff in different departments are witnessed wearing their masks down, not wearing masks properly, and not wearing masks altogether. Based on interviews with S1-S4, (4) of (4) staff denied the allegations and stated that all staff are frequently reminded to wear masks at all times while working in the facility. S1-S3 also stated that in-service training was recently provided to staff regarding COVID-19 procedures in the facility, to ensure compliance in the guidance from Licensing and DPH. (4) of (7) residents stated they have not witnessed staff not wearing masks and have no concerns of it. During the tour of the physical plant, LPA observed all staff at the facility to be wearing face masks, including visitors coming who were entering the building.

Based on LPA observations, interviews conducted, and records review: Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

An exit interview was held with Administrator Steven Fairchild and a copy of the report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20221212113149

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: 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 CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents... (a)...residents...shall have... the following personal rights:(4)...care, supervision, and services that meet their individual needs... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The administrator will provide in-service training for all care staff and provide a copy of the training material with the sign-in sheet to LPA via email by the POC due date.
	8 9 10 11 12 13 14	Based on observations, interviews, records review, the licensee failed to ensure staff are meeting resident's needs in a timely manner when their call lights are used, which poses a potential Health, Safety, or Personal Rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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