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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602870
Report Date: 09/19/2023
Date Signed: 09/19/2023 11:24:50 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: 59DATE:
09/19/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Heather O'Neel- Health Services DirectorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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9
Resident was left in a soiled diaper for a long period of time.
INVESTIGATION FINDINGS:
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13
**Please note: This report will supersede the original report dated 1/31/23, due to additional interviews conducted and new information to be included in the report. Per new information, the findings have changed for this allegation and will be Substantiated.**

Licensing Program Analyst (LPA) V. Maldonado made an unannounced subsequent visit at the facility for the purpose of issuing a new complaint report regarding the above-mentioned allegations. LPA Maldonado met with Director of Health Services, Heather O’Neel, and explained the purpose for the visit.
On 1/31/23, LPA Maldonado 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).

(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: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
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: 09/19/2023
NARRATIVE
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During today’s visit, LPA Maldonado obtained a copy of the resident and staff roster, charting notes for R1 for the month of January 2023, and conducted interviews with Residents# 2-4 (R2-R4).
The investigation revealed the following:

Regarding allegation: Resident was left in a soiled diaper for a long period of time.
It is alleged that beginning January 12, 2023, and for the rest of the month, R1 did not receive sufficient brief changes throughout the day. Per interviews conducted, (5) of (5) denied the allegation and stated the resident was receiving frequent changes. It was stated that facility policy is to check residents who require brief change, every 2 hours, and change the resident regardless of output/soiled status. Per R1's MAR, it was discovered that R1's continence output was measured and documented every day by facility staff for the entire month of January 2023. Per charting notes obtained, it was noted that as of January 12th through the 31st, 2023, staff only documented brief changes that occurred during the morning shift every day, documented evening shift brief change on January 15, 2023, only, and on January 28, nothing was documented at all. On 1/31/23, LPA attempted to interview R1 regarding this allegation, but R1 was unable to answer due to cognitive impairment. (3) of (4) residents interviewed could not corroborate the allegation. 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 Director of Health Services, Heather O’Neel, 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: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 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: 09/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/06/2023
Section Cited
CCR
87625(b)(2)
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87625 Managed Incontinence
(b)...the licensee shall be responsible for the following: (2) Ensuring that incontinent residents are checked during..periods...when they are known to be incontinent, including during the night.
This requirement was not met as evidenced by:
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Licensee to conduct Managed Incontinence Care training with direct care staff, only. Training material and attendance/sign-in sheet to be sent to LPA, via email, by the POC due date, as proof of training completed.
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Based on interviews and documents reviewed, the licensee failed to ensure that (1) of (4) residents was being checked regularly and assisted with brief changes as required, 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: 09/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
LIC9099 (FAS) - (06/04)
Page: 3 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
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: 59DATE:
09/19/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Heather O'Neel- Health Services DirectorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident is confined to a bed for a long period of time.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
**Please note: This report will supersede the original report dated 1/31/23, due to additional interviews conducted and new information, to be included in the report. However, the findings for this allegation will not change and will remain the same: Unsubstantiated.**

Licensing Program Analyst (LPA) V. Maldonado made an unannounced subsequent visit at the facility for the purpose of issuing a new complaint report regarding the above-mentioned allegations. LPA Maldonado met with Director of Health Services, Heather O’Neel, and explained the purpose for the visit.

On 1/31/23, LPA Maldonado 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).
(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: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
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 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: 09/19/2023
NARRATIVE
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During today’s visit, LPA Maldonado obtained a copy of the resident and staff roster, charting notes for R1 for the month of January 2023, and conducted interviews with Residents# 2-4 (R2-R4).

The investigation revealed the following:

Regarding allegation: Resident is confined to a bed for a long period of time.


It is alleged that R1 is confined to R1’s bed. Per R1's Physician's Report, R1's physical status indicates that R1 requires continuous bed care and is non-ambulatory due to history of recent surgery. Per interviews conducted, (5) of (5) staff stated R1 is unable to move much on their own and requires repositioning every 2 hours. Per R1’s Hospice Care Plan, R1 requires maximum assistance in (6) of (6) Activities of Daily Living (ADL’s) and is a high fall risk. The Hospice Care Plan also indicated that R1 is bed bound due to weakness and more foot drop being noted. Per Hospice Care Plan, R1 is to be transferred to a geri chair via hoyer lift every morning for 45 minutes, as tolerated due to increased back pain and body stiffness. On 1/31/23, LPA attempted to interview R1 regarding this allegation, but R1 was unable to answer due to cognitive impairment. (3) of (4) residents interviewed could not corroborate the allegation. This allegation is unsubstantiated.

Based on LPA's observations, records review, and interviews held: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Per California Code of Regulations, Title 22, no deficiencies were observed or cited.

An exit interview was conducted with Director of Health Services, Heather O’Neel, and a copy of this report was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5