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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 11:08:15 AM

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
01/25/2023 and conducted by Evaluator Valeria Maldonado
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230125155313
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: 67DATE:
08/10/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Steven Fairchild- Exective DirectorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility is not ensuring that resident is being fed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced subsequent visit to the facility for the purpose of delivering findings on the above-mentioned allegation. LPA Maldonado met with Executive Director Steven Fairchild and explained the purpose for the visit.

On 1/31/23, LPA Maldonado made an initial visit to the facility for the purpose of investigating the above-mentioned allegation. During the visit, LPA obtained a copy of the resident/staff roster, and the following documents for Resident# 1 (R1): Facesheet, Physician's Report, Pre-Placement Appraisal, Needs and Services Plan, Admissions Agreement, Power of Attorney, Medication Administration Records (MAR's), Hospice Care Plan, and Hospice Notes. LPA also interviewed Staff# 1-5 (S1-S5) and attempted to interview Resident# 1 (R1).

During today's visit, LPA obtained a copy of R1's Hospice Care Plan, as the initial one provided was facility hospice intake, not the direct hospice care plan. (Report continued on LIC9099-C...)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
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 5
Control Number 28-AS-20230125155313
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: 08/10/2023
NARRATIVE
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The investigation revealed the following:
Regarding allegation- Facility is not ensuring that resident is being fed.
It is alleged that on January 13, 2023, R1's relative arrived during lunch time to visit and was going to assist with feeding. Upon arrival, R1's relative noted R1's full tray of food was there and informed staff to not bring anything. Staff allegedly informed R1's relative that the food tray there was not lunch, but rather, still the tray from breakfast and therefore, R1 was not fed breakfast. Per R1's relative, S5 informed R1's relative that R1's bathing aid from hospice would assist with feeding as a courtesy, but did not, and left without notifying S5 that R1 was not fed. Per R1's Hospice Care Plan, hospice staff/aids are not responsible for assisting R1 with feeding. Per R1's Physician's Report and Pre-Placement Appraisal, R1 requires full assistance with feedings due to their health and cognitive impairments. During the incident that occurred on January 13, 2023, R1's relative brought this to S1's attention and S1 spoke to S5 about it. Per S1, S5 stated that this did in-fact occur and S1 stated S5 was given additional training to ensure this does not occur again in the future with other residents. Per interview held with S5, the hospice aid informed S5 that they would assist with feeding R1 after their bath, but failed to do so and failed to notify S5 of it. During lunch on January 13, 2023, S5 stated that R1's relative noticed 2 food trays in R1s room and notified S5 of it. That is when S5 stated to realize that R1 was not fed by the hospice bath aid. Therefore, this allegation is substantiated.

Based on LPA's observations and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is SUBSTANTIATED.

Per California Code of Regulations, Title 22, deficiencies will be cited on the LIC9099-D.

An exit interview was conducted with Executive Director 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: 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 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
01/25/2023 and conducted by Evaluator Valeria Maldonado
COMPLAINT CONTROL NUMBER: 28-AS-20230125155313

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: 67DATE:
08/10/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Steven Fairchild- Exective DirectorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
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9
Resident's needs are not being met.
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) V. Maldonado made an unannounced subsequent visit to the facility for the purpose of delivering findings on the above-mentioned allegation. LPA Maldonado met with Executive Director Steven Fairchild and explained the purpose for the visit.

On 1/31/23, LPA Maldonado made an initial visit to the facility for the purpose of investigating the above-mentioned allegation. During the visit, LPA obtained a copy of the resident/staff roster, and the following documents for Resident# 1 (R1): Facesheet, Physician's Report, Pre-Placement Appraisal, Needs and Services Plan, Admissions Agreement, Power of Attorney, Medication Administration Records (MAR's), Hospice Care Plan, and Hospice Notes. LPA also interviewed Staff# 1-5 (S1-S5) and attempted to interview Resident# 1 (R1).

During today's visit, LPA obtained a copy of R1's Hospice Care Plan, as the initial one provided was facility hospice intake, not the direct hospice care plan. (Report continued on LIC9099-C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
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: 3 of 5
Control Number 28-AS-20230125155313
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: 08/10/2023
NARRATIVE
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The investigation revealed the following:
Regarding allegation- Resident's needs are not being met.
It is alleged that the facility staff has neglected to check on R1 for over 4 hours at a time- specifically between breakfast and lunch time, to ensure R1 is okay and if R1 requires assistance with anything. Per interviews conducted with S1-S5, R1 is being checked on every two hours, as R1 requires repositioning in bed. R1 also requires brief changes and those are conducted by staff every two hours, per the facility policy. Per interviews, R1 is unable to communicate needs, and therefore required frequent checks. LPA attempted to interview R1 and was unable to, due to R1's cognitive impairment. As LPA asked questions, R1 was observed to not understand the questions and could not respond to them. Per R1's Physician's Report and Needs and Services Plan, R1 requires full assistance with Activities of Daily Living and was admitted to the facility under hospice care. This allegation is Unsubstantiated.

Per California Code of Regulations, Title 22, no deficiencies were observed or cited during today's visit.

An exit interview was conducted with Executive Director Steven Fairchild and a copy of the report was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
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: 4 of 5
Control Number 28-AS-20230125155313
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: 08/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/18/2023
Section Cited
HSC
1569.73
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Terminally ill residents; or terminally ill persons to be accepted as a resident; transferring hospice care and waivers; resident care and supervision
(3) The facility... has the ability to provide care and supervision appropriate to meet the needs of the terminally ill resident...
This requirement was not met as evidenced by:
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Staff who provide direct care to residents will be given training to ensure residents needs are being met and appropriate care is being provided. A copy of training material and sign in sheet will be emailed to LPA via email by POC due date.
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Based on LPA's observations, interviews, and file review, facility staff failed to provide care appropriate to R1, when they failed to feed R1 a meal, which poses a potential Health, Safety, or 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: 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: 5 of 5