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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602870
Report Date: 01/30/2024
Date Signed: 01/30/2024 03:41:23 PM

Unsubstantiated


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
08/09/2023 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230809160836
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: 61DATE:
01/30/2024
UNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Heather O'Neel,TIME COMPLETED:
03:58 PM
ALLEGATION(S):
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Facility is malodorous.
Facility staff is not assisting resident with grooming.
Facility staff not assisting resident with oral hygiene.
Facility A/C unit is in disrepair.
Staff are not adequately trained.
Facility is not clean.
Facility is retaining residents with higher level of care needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alberto Lopez conducted a subsequent complaint visit to investigate the allegations listed above. LPA explained the purpose of the visit. LPA met with Administrator, Charles Brugh and Heather O’Neel, Heath Services Director who assisted with the visit.

During the initial visit on 08/10/2023 LPA conducted a tour with Administrator of the living room, dining areas, kitchen, common areas and random resident rooms in assisted living and memory care unit. LPA did not observe any signs of neglect, abuse or other immediate health and safety threats. LPA requested copies of staff and resident roster and interviewed two staff (S1-S2) LPA asked Administrator to provide LPA with First aid/CPR certificates for staff on all shifts. Other documents will be requested on a subsequent visit.
During visit on 01/26/2024 LPA took tour of memory care, 2nd floor in assisted living, kitchen, 2nd floor laundry room and common areas with staff. LPA interviewed 6 additional staff S#3-S#8. LPA reviewed and obtained copies of staff CPR certificates. LPA requested Point click care for residents in memory care for the month of August 2023. (CONTINUED ON 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
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
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
08/09/2023 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230809160836

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:
01/30/2024
UNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:TIME COMPLETED:
03:58 PM
ALLEGATION(S):
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Facility silverware are not properly cleaned.
INVESTIGATION FINDINGS:
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Allegation: Facility silverware are not properly cleaned. It is alleged that the silverware and glassware at the facility is dirty. LPA took tour of kitchen on the first two separate visits and inspected the silverware and glassware each time and the silverware and glassware appeared to be clean. The silverware did have water spots, however, that is not an indication that the silverware is dirty and due to hard water used to wash the silverware. LPA interviewed 10 staff and 10 of 10 staff denied the allegations. LPA interviewed 8 residents and 7 of 8 residents stated that silverware is clean. One resident stated glassware is foggy and LPA and staff observe the glassware to be foggy due to hard water used to wash the glassware. On third visit, LPA and Staff noticed one butter knife that was unclean and removed promptly by staff to wash. There is enough evidence to substantiate this allegation.

Deficiency cited on 809D

Exit interview conducted and copy of report, 9099D and appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20230809160836
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: 01/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/31/2024
Section Cited
CCR
87555(b)(30)
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(b) The following food service requirements shall apply:
(30) All utensils used for eating and drinking and in preparation of food and drink, shall be cleaned and sanitized after each usage.

This requirement is not met evidenced by:
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Staff removed the butter knife from storage bin and alerted kitchen staff to the unclean utensil and storage bin. Staff took immediate action to clean the utensil and storage bin.

****no further action required***
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LPA and staff observed one knife in kitchen that was uncleaned and the storage bin for the silverware had debris.
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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20230809160836
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: 01/30/2024
NARRATIVE
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During current visit on 01/30/2024 LPA interviewed 8 residents (R#1-R#8) and 2 additional staff S#9-S#10 and took tour of memory care area and tested the fire doors. One fire door leading from the courtyard was not operating properly and that is addressed in a case management 809 and 809D report.

During current visit LPA took another tour of facility and random rooms and interviewed 8 residents and 2 additional staff #9-#10 and obtained invoices from Air temperature, INC who service the A/C at facility, proof of ongoing training, and documentation survey report for 4 random residents in memory care that documents service provided to residents for month of July 2023 and August 2023.

The investigation revealed:

Allegation: Facility is malodorous. It is alleged that the facility has bad odor. LPA interviewed 10 staff and 9 of 10 staff denied the allegations. LPA interviewed eight residents R#1-R#8 and 6 of 8 could not collaborate the allegations. LPA investigated a similar complaint in April of 2023 and facility took action to eliminate the odor and during tour of facility on 2 recent separate visits, LPA did not smell odor and facility was not malodorous. There is no evidence to substantiate this allegation.

Allegation: Facility staff is not assisting residents with grooming. It alleged that facility staff are not assisting residents with their grooming needs. LPA interviewed 8 staff and 8 of 10 staff denied the allegation and stated that they will take care of grooming needs for residents even if it’s not on residents care plan. 2 staff stated that they are not a caregiver and would not know. LPA interviewed 8 residents and 7 of 8 stated they do their own grooming. 1 of 2 residents in memory care stated they do they own grooming, and one resident had just got out of bed and unable to answer questions. There is no evidence to substantiate this allegation.

Allegation: Facility staff not assisting resident wit oral hygiene. It is alleged that staff is not assisting residents with oral hygiene. LPA interviewed 10 staff and 7 of 10 staff denied the allegations. 5 staff stated that they will assist with oral hygiene for any resident that needs it regardless if the service is in their care plan or not. 3 staff could not answer as oral hygiene is not part of their duties LPA interviewed 8 residents and 7 of 8 stated they do their own oral hygiene. One resident did not answer question. There is no evidence to substantiate this allegation.

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20230809160836
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: 01/30/2024
NARRATIVE
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Allegation: Facility A/C unit is in disrepair. It is alleged that facility A/C is not functioning properly. LPA interviewed 10 staff and 6 of 10 denied the allegation. One staff stated, “we have issues here and there” and another staff stated that the A/C does not work in some rooms but could not identify the rooms but stated that staff are on it right away. LPA inspected random rooms 153, and 337 and checked A/C and A/C was operating properly. LPA interviewed 8 residents and 7 of 8 residents stated that their A/C functions properly. The A/C in room 234 has not been working for 2 weeks now. Work orders for room 234 A/C were reviewed and obtained by LPA for 09/2023. Resident was provided a portable cooler while they repair the A/C. R1 stated R1 is comfortable with the portable cooler and can wait while the facility repairs it. The facility A/C was functioning properly during the 3 separate visits to facility. There is no evidence to substantiate this allegation.

Allegation: Staff are not adequately trained. It is alleged that management and activity staff are not trained in CPR. LPA interviewed 10 staff and all 9 of 10 staff denied that allegation and stated they are up to date on the training and trained in first aid/CPR. LPA reviewed and obtained copies of CPR certification from 19 current staff. LPA reviewed and obtained recent ongoing training documentation from six random staff. Management are CPR certified. There is no evidence that staff are not adequately trained.

Allegation: Facility is not clean. LPA took a tour of facility common areas and random rooms on each floor and memory care during the 3 separate visits and facility was clean. 10 of 10 staff denied the allegations. LPA interviewed 8 residents and 8 of 8 could not collaborate the allegations. There is no evidence to substantiate this allegation.

Allegation: Facility is retaining residents with higher level of care needs. It is alleged that one resident is diabetic and requires a higher level of care. LPA interviewed 10 staff and 10 of 10 staff denied the allegation. LPA interviewed R4 and 7 other residents, and they could not collaborate the allegations. There is no evidence to substantiate this allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5