306004685-2-12-2024-22-AS-SSAS-D2F2GP-20240213162328

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004685
Report Date: 02/12/2024
Date Signed: 02/12/2024 02:30:49 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/13/2023 and conducted by Evaluator Celine DePerio

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20231113082337

FACILITY NAME:	SERENITY SENIOR CARE HOME		FACILITY NUMBER:	306004685
ADMINISTRATOR:	MINERVA SANSANO		FACILITY TYPE:	740
ADDRESS:	22952 COUNCIL BLUFFS		TELEPHONE:	(949) 600-7757
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	6	CENSUS: 6	DATE:	02/12/2024
		UNANNOUNCED	TIME BEGAN:	12:42 PM
MET WITH:	Staff on duty- Renato Manuel		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Staff are not following resident's doctor's orders.
Staff are not following admissions agreement

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced visit to the facility to deliver the findings. LPA De Perio explained the purpose of today's visit, was greeted, and granted entry by staff on duty (S1) Renato Manuel. S1 notified facility administrator (AD), however AD was unable to be present during time of visit, and provided consent for S1 to receive and sign the report.

It was alleged that staff are not following resident's doctor's orders. 6 out of 6 resident interviews conducted, did not corroborate with the allegation. 2 out of 2 staff interviews conducted, also did not corroborate with the allegation by stating that per resident (R1) hospice medication list, as of 11/13/23, R1's zyprexa medication is only a PRN medication, as of 11/12/23, R1 is to be given depakote once a day during bedtime, and as of 11/6/23, R1 was prescribed steristrip, xeroform, and calmoseptine for a wound on R1's arm. During the tour of the facility, LPA observed that R1 had the steristrip and zeroform on their arm, however, was actively attempting to remove it.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20231113082337

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SERENITY SENIOR CARE HOME	FACILITY NUMBER: 306004685
	VISIT DATE: 02/12/2024

NARRATIVE

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Per documentation review and review of medication tablets, LPA De Perio verified that R1 is receiving the zyprexa has needed, and the depakote is only being given once during bedtime. 1 out of 1 interview conducted with witness (W1) stated that W1 wanted to increase the medication dosages for R1, however was informed that R1 would need a doctor's order before moving forward with any medication changes.

It was alleged that staff are not following admissions agreement. 6 out of 6 resident interviews conducted, did not corroborate with the allegation. 2 out of 2 staff interviews conducted did not corroborate with the allegation by stating that prior to admission, the facility will review the admission agreement with the resident and family, and will also discuss about the criteria for eviction if necessary (such as if a resident needs a higher level or care, non-compliance, violation of laws and house rules). LPA De Perio observed that all 6 residents residing at the facility had signed admission agreements by their responsible parties.

Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED.

An exit interview was conducted with S1 Manuel.

A copy of this report was explained and provided.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

LIC9099 (FAS) - (06/04)

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