198602870-8-22-2023-28-AS-LHIS-CVLKGZ-20230912075423

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602870
Report Date: 08/22/2023
Date Signed: 08/22/2023 03:01:59 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
08/16/2023 and conducted by Evaluator Alberto Lopez

COMPLAINT CONTROL NUMBER: 28-AS-20230816100335

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: 21	DATE:	08/22/2023
		UNANNOUNCED	TIME BEGAN:	10:36 AM
MET WITH:	Marie Stern, Director of Operations		TIME COMPLETED:	03:16 PM

ALLEGATION(S):

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Facility fire gate is in disrepair

INVESTIGATION FINDINGS:

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LPA made unannounced 10-day visit to investigate the above allegation, LPA met with Director of Operations Marie Stern and explained the purpose of the visit.

The investigation consisted reviewing staff and residents rosters, reviewing original estimate of repair dated 06/19/2023 and a tour of the memory care unit and interviews with five staff (S1-S5) and one witness (W1). LPA attempted to interview residents in memory care but was unable to.

Allegation: Facility fire gate is in disrepair. It is alleged that fire door in memory care unit that leads to the outside parking lot is not functioning properly and that the alarm that notifies staff that there is an elopement is not working and is zipped tied which creates a safety hazard for residents. The investigation revealed: Five of five staff interviewed collaborated the allegations and stated that they are aware of the door not functioning as it should. S1 stated that facility placed an order for repair back in June of 2023 and that the repair company (Johnson Controls) is just waiting for the part that was placed on back order.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

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-20230816100335

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: 08/22/2023

NARRATIVE

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. LPA obtained copy of original estimate and contacted Ronnie Zahm (W1) of Johnson Controls Fire Protection LP (W1). W1 stated that his company has been waiting for the parts to arrive to complete repairs on the fire door that leads from courtyard to the outside parking lot of facility. W1 stated that the parts are scheduled to arrive on Monday 08/28/2023 or Tuesday 08/29/2023 and that he will send someone to complete the repairs on that fire door. While taking a tour of the memory care unit, LPA and S5 tested the other 2 fire doors inside the memory care unit and the fire door by room 170 is not functioning properly and needs repair. This fire door by room 170 should unlock after pressing on the lever for 15 seconds. However, LPA tested that door, and it remains locked after 15 seconds and longer and the only way to unlock it is by staff entering a code on the wall adjacent to the door. S1 stated that they will have the company that is coming to repair the other fire door look at it to find a solution. LPA inspected all 3 fire doors, and none were zipped tied at the time of visit. Several staff mentioned that one fire door outside was zipped tied for a while but not anymore. Facility has addressed the faulty door outside by placing a staff outside to monitoring the entering and exiting of the fire door outside 24 hours a day. Although the fire door specified in the complaint has been addressed, it is still not repaired and has been in disrepair for at least 2 months and the facility will need to address the other fire door by room 170 that is not functioning properly and repair or replace it as it posses a health and safety issue.

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 Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230816100335

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: 08/22/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/01/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	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:	1 2 3 4 5 6 7	Administrator will have both doors repaired or replaced and send LPA proof of correction by POC date.
	8 9 10 11 12 13 14	Two fire doors in the memory care unit are not functioning as they should. One fire door leading to the parking lot is waiting for parts to be repaired and one fire door inside by room 170 is in need of repair as it does not function as it should.	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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC9099 (FAS) - (06/04)

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