198602870-4-8-2022-28-AS-MVAO-CDEVS7-20220412164105

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602870
Report Date: 04/08/2022
Date Signed: 04/08/2022 12:00:12 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
03/08/2021 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210308142541

FACILITY NAME:	SERENTO CASA		FACILITY NUMBER:	198602870
ADMINISTRATOR:	KNEEDY-CAYEM, KARA		FACILITY TYPE:	741
ADDRESS:	1740 SAN DIMAS AVENUE		TELEPHONE:	(909) 394-0304
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	131	CENSUS: 53	DATE:	04/08/2022
		UNANNOUNCED	TIME BEGAN:	10:46 AM
MET WITH:	Assistant Administrator, Rania Aggawi		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Facility delayed medical attention to resident after suffering injury at facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vasallo conducted a subsequent complaint investigation for the allegation listed above. LPA Vasallo conducted the initial complaint visit on 3/10/21. Investigator Santana investigated further.

The investigation consisted of the following: Resident #1’s (R1) facility records were obtained which included physician's report, most recent assessment, family contact information, incident reports, nurses’ notes and hospice documents. Interviews were conducted with facility staff which included Caregivers, facility Licensed Vocational Nurses (LVN) and facility Health Services Director. Interviews were also conducted with R1’s physician and R1’s family member(s).

The investigation revealed the following: It’s alleged facility delayed medical attention to R1 after suffering an injury at facility. Interviews with caregivers revealed that on 1/26/21, R1 was complaining of leg pain after being found on the floor that day around 1:40 pm. Continued on 9099C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

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 4

Control Number 28-AS-20210308142541

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: 04/08/2022

NARRATIVE

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The pain was inconsistent with R1’s baseline ailments. Facility Medical Technician (Med Tech) John Reyes reportedly was asked to provide R1 with pain relief medication at approximately 2:15 pm, which was unusual per medication records. Facility LVN Adrian Solano documented on 1/26/21 at 2:51 pm that R1 had been found on the floor of his/her apartment next to the sofa at 1:40 pm. LVN assessed R1 and there were no injures noted so no medical attention was sought, however R1 did complain of left leg pain. Med Tech Reyes documented at 6:26 pm that he again gave R1 more pain medication because R1 continued to complain about leg pain.

An overnight caregiver who worked on 1/26/21 reported that her co-workers stated R1 was in pain and was unable to walk. Caregivers reported that R1 required a 2-person assist when toileting. Prior to the fall R1 only required a 1-person assist. The same overnight caregiver witnessed R1’s left leg externally rotated, and caregiver reported this to Taisha DeCorse, facility Health Services Director at approximately 5:30 am on 1/27/21. The Health Services Director responded and said the morning shift LVN would address it. On 1/27/21 at approximately 7:10 am, the morning shift LVN called 911. This is approximately 17 hours after R1 was believed to have sustained the injury from the fall. Hospital medical records reveal resident’s left hip joint was fractured.

R1’s physician’s notes indicate that "Per care staff, dementia is progressing". R1 did not reside on the dementia unit as would be required for a resident with dementia. Hospice evaluation documents also state R1’s dementia was worsening and was a fall risk. The facility failed to put R1 in the dementia unit even though the facility staff knew about R1’s progressing dementia. After R1 was found on the floor, the facility allowed the resident to go approximately 17 hours without seeing a physician or going to the hospital even though R1 complained about leg pain.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the allegations are found to be substantiated. The deficiencies are being cited on the attached LIC 9099D.

Exit interview held and a copy of the report and appeal rights were provided to Assistant Administrator. The issuance of a civil penalty is being considered based on Health & Safety Code 1569.49(f); if the department determines serious bodily injury was a result of neglect.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210308142541

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: 04/08/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/11/2022 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and	1 2 3 4 5 6 7	Facility will conduct staff training as it relates to this incident. Training plan will be submitted by by POC due date. An immediate civil penalty will be assessed in the amount of $500.
	8 9 10 11 12 13 14	are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This deficiency was evidenced by the following: R1 was complaining of leg pain after a fall. R1 did not receive medical attention until 17 hours after fall. The fall resulted in a fracture.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

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
03/08/2021 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210308142541

FACILITY NAME:	SERENTO CASA		FACILITY NUMBER:	198602870
ADMINISTRATOR:	KNEEDY-CAYEM, KARA		FACILITY TYPE:	741
ADDRESS:	1740 SAN DIMAS AVENUE		TELEPHONE:	(909) 394-0304
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	131	CENSUS: 53	DATE:	04/08/2022
		UNANNOUNCED	TIME BEGAN:	10:46 AM
MET WITH:	Assistant Administrator, Rania Aggawi		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Facility not cleaned adequately.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vasallo conducted a subsequent complaint investigation for the allegation listed above. LPA Vasallo conducted the initial complaint visit on 3/10/21.

The investigation consisted of the following: Facility was toured and staff were interviewed.

The investigation revealed the following: Allegedly around December 2020, R1 was observed having feces on his/her bedroom floor. Around February 2021 allegedly the spot was still on the bedroom floor. R1 moved out in February 2021. LPA toured the facility on 3/10/21 and did not see a spot on R1's prior bedroom. Staff interviewed deny there were any issues with R1's floor. Based on the information obtained, the allegation is unsubstantiated.

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. Exit interview held and a copy of the report was provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

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 4