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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602870
Report Date: 12/01/2021
Date Signed: 12/01/2021 12:19:25 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CASAFACILITY NUMBER:
198602870
ADMINISTRATOR:SARAH SESAYFACILITY TYPE:
741
ADDRESS:1740 SAN DIMAS AVENUETELEPHONE:
(909) 394-0304
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:131CENSUS: 55DATE:
12/01/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Raina Aggawi, Executive DirectorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Vasallo conducted a Case Management Visit to follow-up on an incident report dated 11/30/21. According to the incident report, the facility is reporting possible abuse of a resident. Allegedly on 11/26/21 in the dementia unit, Staff #1 (S1) was observed yelling at Resident #1's (R1) and grabbing both R1's wrists. S1 allegedly was observed shaking and pushing R1 by the wrists. Allegedly S1 was frustrated with R1 because S1 was in the middle of assisting another resident and R1 was bothering S1.

Once reported to facility management, S1 was placed on administrative leave pending investigation. LPA obtained a copy of the facility's investigation, incident report, SOC 341, and police report number. LPA conducted interview with Staff #2 (S2) and R1.

LPA will continue to gather additional information and will return once additional evidence is obtained.

Exit interview held. A copy of the report was provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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