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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602870
Report Date: 02/13/2024
Date Signed: 02/13/2024 11:57:34 AM

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
02/09/2024 and conducted by Evaluator Valeria Maldonado
COMPLAINT CONTROL NUMBER: 28-AS-20240209115250
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:
02/13/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Heather O'Neel- Health Services DirectorTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff do not maintain facility in good repair.
Staff do not ensure that hazardous material is stored locked and inaccessible to resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced complaint visit to the facility for the purpose of investigating the above-mentioned allegations. LPA Maldonado met with Health Services Director (HSD), Heather O'Neel and explained the purpose for the visit.

During today's visit, LPA Maldonado obtained a copy of the resident and staff roster, obtained the Facesheet and Phsycian's Report for Resident# 1 (R1), and conducted a tour of the physical plant in the memory care unit with HSD Heather. LPA also conducted interviews with Staff#1-5 (S1-S5) and Residents#1-4 (R1-R4).

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: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024
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 2
Control Number 28-AS-20240209115250
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: 02/13/2024
NARRATIVE
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Regarding allegation: Staff do not maintain facility in good repair.
It is alleged that in the memory care unit, a ceiling tile is missing in R1's room above the toilet, the back gate is not properly sounding the alarm as required when opened, light fixtures in the television room are missing, some of the light fixtures appear to be falling off, and window blinds are broken. LPA observed R1's room and did not observe any ceiling tiles missing, nor were there any missing throughout the memory care unit. LPA observed the activity/television room and did not observe any light fixtures appearing to be falling, missing light bulbs, or window blinds broken. LPA did not observe any of these items to be missing, falling, or broken in resident rooms or common areas either. LPA pushed open the back gate in the memory care unit and observed it to be delayed egress as well as sound the alarm as required. Per interviews with staff, (5) of (5) staff denied the allegation and stated that if there are any maintenance issues, a work order is submitted once they become aware of the problem and maintenance staff will address it within 1-2 days, depending on the urgency. Per resident interviews, (3) of (4) residents denied the allegation and stated they have no issues with the facility being in disrepair. (1) Resident could not corroborate the allegation.
Regarding allegation: Staff do not ensure that hazardous material is stored locked and inaccessible to resident.
It is alleged that in the memory care unit, the laundry room is not maintained locked, and have laundry detergent accessible to them. LPA Maldonado inspected the laundry room, random resident rooms, shared bathrooms, common areas, dining room, and storage rooms. In the memory care unit, LPA observed the laundry room and storage rooms to be locked and inaccessible to residents in care. Upon opening the laundry room, storage rooms, and bathrooms, LPA did not observe any toxins/cleaning supplies or sharps stored. In the dining room, there was a cabinet underneath the sink where dishwashing soap was stored, but was observed to be locked. Per staff interviews, (5) of (5) staff denied the allegation and stated there are no toxins/cleaning supplies stored in the memory care unit. They are stored in storage in the assisted living side and only housekeeping maintains them on their cart. However, housekeeping maintains their cleaning cart with them at all times. LPA observed housekeeping staff cleaning rooms during the visit and observed the cart to be supervised at all times by the staff. Per resident interviews, (4) of (4) residents could not corroborate the allegation.

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: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024
LIC9099 (FAS) - (06/04)
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