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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602870
Report Date: 10/09/2023
Date Signed: 10/09/2023 09:40:16 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
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: DATE:
10/09/2023
UNANNOUNCEDTIME BEGAN:
08:56 AM
MET WITH:Hrag Bekerian- Executive DirectorTIME COMPLETED:
09:45 AM
ALLEGATION(S):
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Facility is not ensuring that resident is being fed.
Resident's needs are not being met.
INVESTIGATION FINDINGS:
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**Please note: This report will supersede all previous reports dated 1/31/23, 8/10/23, and 9/19/23 to keep all allegations of the complaint together on one report. However, the findings have changed to Substantiated, for the allegation: Resident’s needs are not being met. The findings for the other allegation will remain the same- Substantiated.**
Licensing Program Analyst (LPA) V. Maldonado made an unannounced subsequent visit to the facility for the purpose of issuing a superseded report, regarding the above-mentioned allegations. LPA Maldonado met with Executive Director, Hrag Bekerian, 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). On 8/10/23, 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. On 9/19/23, 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). (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: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023
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: 10/09/2023
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, Witness#1 (W1) arrived during lunch time to visit and was going to assist with feeding. Upon arrival, W1 noted R1's full tray of food was there and informed staff to not bring anything. Staff allegedly informed W1 that the food tray there was not lunch, but rather, still the tray from breakfast and therefore, R1 was not fed breakfast. Per W1, S5 informed W1 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 R1’s health and cognitive impairments. W1 brought this incident to S1's attention and S1 spoke to S5 about it. Per S1, S5 admitted to the incident occurring 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 R1’s bath, but failed to do so, and failed to notify S5 of it. During lunch on January 13, 2023, S5 stated that W1 noticed 2 food trays in R1s room and notified S5 of it. That is when S5 stated to have realized that R1 was not fed by the hospice bath aid.
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, staff stated that R1 is checked every two hours, as R1 requires repositioning in bed. Staff also stated R1 requires brief changes and those are completed every two hours, per the facility policy. Per interviews, R1 is unable to communicate needs, and therefore requires 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 feeding. On January 13, 2023, facility staff admitted to not feeding R1 breakfast, as the hospice aid offered to feed R1, although per R1’s Hospice Care Plan, the hospice company is not required to provide this service. The facility failed to meet the R1’s need.
Based on LPA's observations, records review, and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are Substantiated.
Per California Code of Regulations, Title 22, deficiencies will be cited on the LIC9099-D.
Exit interview was conducted 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: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023
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: 10/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/20/2023
Section Cited
HSC
1569.73(a)(3)
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(a)...allowing a resident who has been diagnosed as terminally ill by his or her physician...would continue to receive hospice services without disruption... when all the following conditions are met:(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 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: 10/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023
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: DATE:
10/09/2023
UNANNOUNCEDTIME BEGAN:
08:56 AM
MET WITH:TIME COMPLETED:
09:45 AM
ALLEGATION(S):
1
2
3
4
5
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7
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9
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:
1
2
3
4
5
6
7
8
9
10
11
12
13
**Please note: This report will supersede all previous reports dated 1/31/23, 8/10/23, and 9/19/23 to keep all allegations of the complaint together on one report. However, the findings have changed to Unsubstantiated, for the allegation: Resident was left in a soiled diaper for a long period of time. The findings for the other allegation will remain the same- Unsubstantiated.**
Licensing Program Analyst (LPA) V. Maldonado made an unannounced subsequent visit to the facility for the purpose of issuing a superseded report, regarding the above-mentioned allegations. LPA Maldonado met with Executive Director, Hrag Bekerian, 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). On 8/10/23, 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. On 9/19/23, 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). (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: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023
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: 10/09/2023
NARRATIVE
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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 that R1 was being changed every two hours, as that is the facility’s policy, 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 Unsubstantiated.
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. (5) of (5) staff interviewed stated R1 is unable to move much on their own and requires repositioning every 2 hours. Staff stated to assist R1 with repositioning R1. 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 and requires transferring to a geri chair via hoyer\ lift daily, every morning for 45 minutes, as tolerated. Staff interviewed stated to assist R1 with transferring R1 daily, as tolerated, as R1 has increased back pain. 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.

Exit interview was conducted 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: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5