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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602870
Report Date: 08/10/2023
Date Signed: 08/10/2023 02:54:04 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
08/02/2023 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230802101409
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: 22DATE:
08/10/2023
UNANNOUNCEDTIME BEGAN:
09:51 AM
MET WITH:Steven Fairchild, Administrator TIME COMPLETED:
03:01 PM
ALLEGATION(S):
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Facility is in disrepair.
INVESTIGATION FINDINGS:
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LPA Lopez made unannounced visit to investigate the above allegation, LPA met with Administrator Steven Fairchild and explained the purpose of the visit.

LPA reviewed and obtained resident roster and staff roster and toured the entire memory care unit including rooms 180, 182, 184, 186, 188, 192, 187, 189, 185, 183, 181, 160, 162, 163, 165, 166, 168,169, and 170. LPA interviewed 6 Staff (S1-S6) and five memory care residents (R1-R5)

The investigation revealed the following:

Allegation: Facility is in disrepair. It is alleged that there was water on the floor and the ceiling looked like it was going to collapse in the memory care unit. And there is also damage to the ceiling at end of the hallway in Memory care area.
(Continued on 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
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-20230802101409
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SERENTO CASA
FACILITY NUMBER: 198602870
VISIT DATE: 08/10/2023
NARRATIVE
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Four of six staff denied knowledge of any current leaks. Two of six staff (S5-S6) stated that there was a small leak in room 180 a few weeks ago that was caused by condensation due to resident in room above lowering the thermostat too low. That issue has been resolved.

LPA observed a small crack in the ceiling where water allegedly was breaching the ceiling, LPA did not observe any water entering the room during the visit. Some of the ceiling tiles in memory care unit had old water stains but the plumbing above those tiles was not leaking at the time during the visit. LPA asked maintenance staff to remove stained ceiling tile at the end of the hallway in the memory care unit and LPA placed dry sheets of paper and left them on the ground for over an hour and there was no evidence of a current leak. Five of Five residents interviewed in memory care unit did not collaborate the allegations. The tile at the end of the hall needs to be replaced and one in the memory care activity room, a few tiles in the restrooms of room 183, 165, and 170 need replacement due to old stains on tiles

Based on interviews conducted 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.

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20230802101409
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SERENTO CASA
FACILITY NUMBER: 198602870
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/10/2023
Section Cited
CCR
87303(a)
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87303 (a)
Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times.

This requirement is not met as evidenced by:
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Administrator will replace the tiles that require replacement and will send proof to LPA by POC date.
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LPA and Administrator observed ceiling tile in memory care activity room, one ceiling tile by the end of the hallway in memory care, room 183 bathroom ceiling tile, room 165 bathroom ceiling tile, and room 170 ceiling tile in the memory care unit are in need of replacement due to stains.
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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
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
GREATER LA AC/SC, 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
08/02/2023 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230802101409

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: 22DATE:
08/10/2023
UNANNOUNCEDTIME BEGAN:
09:51 AM
MET WITH:Steven Fairchild, Administrator TIME COMPLETED:
03:01 PM
ALLEGATION(S):
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Staff does not ensure that facility provides a safe environment for residents in care.
INVESTIGATION FINDINGS:
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Allegation: Staff does not ensure that facility provides a safe environment for residents in care. It is alleged that facility is not providing a safe environment for residents due to water leaks and disrepair.
LPA interviewed five residents in memory care unit and all five stated they are provided a safe environment and are happy here. Staff interviewed denied the allegations. Although there are some tiles that have old water stains and need replacement, it does not prevent residents from being provided a safe environment.

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 allegation is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
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