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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602870
Report Date: 01/18/2024
Date Signed: 01/18/2024 02:51:02 PM

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
01/12/2024 and conducted by Evaluator Valeria Maldonado
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240112115658
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: 62DATE:
01/18/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Tucker Brugh- Executive DirectorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility is in disrepair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) V. Maldonado made an initial complaint visit to the facility for the purpose of investigating the above-mentioned allegations. LPA Maldonado met with Executive Director, Tucker Brugh, Health Services Director, Heather O'Neel, and Director of Operations, Marie Stern. The purpose for the visit was discussed.

During today's visit, LPA Maldonado obtained a copy of the resident and staff roster, plumber's work invoice dated: 1/12/24, a cleaning and reparation company's planned work invoice, dated: 1/17/24, and an environmental assessment report for mold dated: 1/16/24, and documented notices indicating R1's decline/refusal to move rooms during repairs. LPA also obtained the Facesheet and Physician's Report for Resident# 1 and conducted interviews with Residents# 1-4 (R1-R4) and Staff# 1-5 (S1-S5).

The investigation revealed the following:
(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: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
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
Control Number 28-AS-20240112115658
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: 01/18/2024
NARRATIVE
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Regarding allegation: Facility is in disrepair.
It is alleged that on 1/09/24, it was reported that there was a leak in R1’s room, which left the room floor wet and plumbers came to repair it by cutting into the wall. Per interviews conducted, (5) of (5) staff admitted to there being a leak in R1’s room. Per S2, S2 went to inspect the leak when it was reported and contacted a plumbing company the same day. Per interviews conducted, (3) of (4) residents could not corroborate the allegation. The plumber’s work invoice dated: 1/12/24, indicates that between 1/09/24-1/12/24, repairs took place in R1’s room where the drywall area was cut out, damaged piping was cut out, and the shower’s drain was replaced with a new one. It was tested and observed to no longer be leaking. This reflects that the reparations took three days to complete. LPA inspected R1’s room and observed a large mat placed over the piece of the carpet that was allegedly wet. LPA also observed a piece of the wall next to R1’s bed that appears to have been cut out in a square and replaced with a newer one, as it has a different color of the original wall. The square has tape placed all around and is held with nails. The bathroom shower also has exposed green drywall all around the edges of it. Per S1 and S3, the reparations will be completed sometime next week by another company as they will be doing professional cleaning due to mold that was found on the wall when the wall was cut out to complete the plumbing reparations.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found to be Substantiated.

Per California Code of Regulations, Title 22, deficiencies are being cited on the attached LIC9099-D.

An exit interview was conducted and a copy of this 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: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20240112115658
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: 01/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/02/2024
Section Cited
CCR
87303(e)(6)
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87303 Maintenance and Operation
(a) The facility shall be...in good repair at all times...

This requirement was not met as evidenced as:
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Repair invoices and pictures of work completed in R1's bathroom and room will be submitted to LPA, via email, by POC due date.
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Based on observation and interviews, R1's room is in disrepair as there is drywall exposed all around the restroom shower and the wall near R1's bed needs to be fixed, which poses a Potential Health, Safety or Personal Rights risks 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: 01/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
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
01/12/2024 and conducted by Evaluator Valeria Maldonado
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240112115658

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: 62DATE:
01/18/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Tucker Bugh- Executive DirectorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
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7
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9
Staff requires resident to sleep in a hazardous room.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) V. Maldonado made an initial complaint visit to the facility for the purpose of investigating the above-mentioned allegations. LPA Maldonado met with Executive Director, Tucker Bugh, Health Services Director, Heather O'Neel, and Director of Operations, Marie Stern. The purpose for the visit was discussed.

During today's visit, LPA Maldonado obtained a copy of the resident and staff roster, plumber's work invoice dated: 1/12/24, a cleaning and reparation company's planned work invoice, dated: 1/17/24, an environmental assessment report for mold dated: 1/16/24, and documented notices indicating R1's decline/refusal to move rooms during repairs. LPA also obtained the Facesheet and Physician's Report for Resident# 1 and conducted interviews with Residents# 1-4 (R1-R4) and Staff# 1-5 (S1-S5).

The investigation revealed the following:
(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: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
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-20240112115658
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: 01/18/2024
NARRATIVE
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Regarding allegation: Staff requires resident to sleep in a hazardous room.
It is alleged that R1 requested to move to another room due to a water leak that occurred in R1's room, which left the floor saturated with water and led to mold being discovered when the wall was opened; However, S1 refused to allow R1 to move rooms. Per interviews conducted, (3) of (5) staff denied the allegation. Staff stated that another room on the second floor was offered to R1 to move into while the repairs occurred, but R1 refused. (2) of (5) staff interviewed could not corroborate the allegation. Per interviews conducted, (3) of (4) residents could not corroborate the allegation. R1 admitted to not wanting to move to a room on the second floor initially, but since reparations will be ongoing in R1's current room, R1 agreed to move temporarily to the room on the second floor. Per facility documented notes and email communications between R1's family and S2, it was discovered that R1 and R1's family agreed to R1 being moved to another room while the reparations are ongoing. Per the environmental assessment report for mold dated: 1/16/24, it is indicated that the mold air and surface samples collected from R1's room and bathroom were considered negative, however, remediation is necessary. Per the cleaning and reparation company's planned work invoice, dated: 1/17/24, cleaning to remove the mold will take place for (3) days and the bathroom wall will be completely replaced due to microbial growth found.

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 allegations are Unsubstantiated.

An 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: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5