198602870-1-31-2023-28-AS-FFIS-CWJUCM-20231012152801

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602870
Report Date: 01/31/2023
Date Signed: 01/31/2023 05:32:48 PM

Unsubstantiated

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 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: 57	DATE:	01/31/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Erin McKinney- Director of Health Services		TIME COMPLETED:	05:35 PM

ALLEGATION(S):

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Resident was left in a soiled diaper for a long period of time.
Resident is confined to a bed for a long period of time.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) V. Maldonado made an unannounced initial complaint visit at the facility for the purpose of investigating the above-mentioned allegations. LPA Maldonado met with Director of Health Services Erin McKinney and explained the purpose for the visit.

During today's visit, 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).

The investigation revealed the following

(Report Continued on LIC9099-C...)

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: 01/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

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-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: 01/31/2023

NARRATIVE

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Regarding allegation: Resident was left in a soiled diaper for a long period of time.
It is alleged that R1 is not receiving sufficient brief changes throughout the day. Per interviews conducted, (5) of (5) stated the facility policy is to check all residents who require brief change, every 2 hrs, 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. LPA attempted to interview R1 regarding this allegation, but R1 was unable to answer due to cognitive impairment. This allegation is unsubstantiated.

Regarding allegation: Resident is confined to a bed for a long period of time.
It is alleged that R1 is confined to their bed. Per R1's physician's report, R1's physical status indicates that they require continuous bed care and are non-ambulatory due to history of recent surgery. Per interviews conducted, (5) of (5) staff stated R1 is unable to move on own and requires repositioning every 2 hours. LPA attempted to interview R1 regarding this allegation, but R1 was unable to answer due to cognitive impairment. 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 and a copy of this 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: 01/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

LIC9099 (FAS) - (06/04)

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