306005294-6-5-2020-22-AS-AORZ-BR53DD-20200701180921

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005294
Report Date: 02/20/2020
Date Signed: 06/05/2020 10:15:16 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
02/14/2020 and conducted by Evaluator Rosie Quiroz

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200214075808

FACILITY NAME:	SERENE SENIOR CARE		FACILITY NUMBER:	306005294
ADMINISTRATOR:	TADEO, CYNTHIA		FACILITY TYPE:	740
ADDRESS:	13092 NEWLAND STREET		TELEPHONE:	(657) 263-4988
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92844
CAPACITY:	6	CENSUS: 3	DATE:	02/20/2020
		UNANNOUNCED	TIME BEGAN:	11:51 AM
MET WITH:	Cynthia Tadeo, Administrator, Geisel Sanchez, Administrator		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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-Facility is in disrepair.

INVESTIGATION FINDINGS:

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On 2/20/2020 at 11:51 am, Licensing Program Analyst (LPA) Rosie Quiroz met with Caregiver (CG) to conduct a 10 day investigation visit regarding the allegation listed above.
At 11:58am, LPA Quiroz along with Administrator Cynthia Tadeo conducted tour of physical plant. At 12:02pm LPA Quiroz observed two (2) outlets in shared bedroom with no electrical power and two (2) outlets in shared bathroom with no electrical power. This was verified with Administrator Cynthia Tadeo who reported "Yes, I'm going to have someone come out and repair." At 12:05am, LPA Quiroz observed broken sliding door leading to back yard and ripped screen.This was verified with Administrator Tadeo, who reported "I will notify our House Manager so he can repair it." Between 12:07pm-12:12pm, LPA Quiroz observed broken blinds throughout the facility. This was verified by Administrator Tadeo, who reported "We will repair them." At 12:14pm, LPA Quiroz observed sliding door behind Resident 1 (R1's) dresser. Administrator verified stating "The resident thinks she's leaving and pulls it off the hinge so she can have enough room to get her things out, but I am going to remove them for safety purposes and update her needs and services plan due to change in behavior."
***Continued on next page***

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2020

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 22-AS-20200214075808

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: SERENE SENIOR CARE	FACILITY NUMBER: 306005294
	VISIT DATE: 02/20/2020

NARRATIVE

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There was a preponderance of evidence to substantiate the allegation noted above. During today's inspection the allegation "facility is in disrepair" was deemed substantiated.
Therefore allegation of "Facility is in disrepair" is found to be SUBSTANTIATED.
The following is being cited per California Code of Regulations Title 22 Division 6. (See LIC 9099-D)

An exit interview was conducted with Administrator Cynthia Tadeo and Administrator Geisel Sanchez, and a copy of this report, 9099-C, 9099-D and Appeal Rights were provided at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2020

LIC9099 (FAS) - (06/04)

Page: 2 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, 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
02/14/2020 and conducted by Evaluator Rosie Quiroz

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200214075808

FACILITY NAME:	SERENE SENIOR CARE		FACILITY NUMBER:	306005294
ADMINISTRATOR:	TADEO, CYNTHIA		FACILITY TYPE:	740
ADDRESS:	13092 NEWLAND STREET		TELEPHONE:	(657) 263-4988
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92844
CAPACITY:	6	CENSUS: 3	DATE:	02/20/2020
		UNANNOUNCED	TIME BEGAN:	11:51 AM
MET WITH:	Cynthia Tadeo, Administrator, Geisel Sanchez, Administrator		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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-Administrator not in the facility sufficient amount of hours.
-Facility administering medications to residents without an authorized physician's request.

INVESTIGATION FINDINGS:

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On 2/20/2020 at 11:51 am, Licensing Program Analyst (LPA) Rosie Quiroz met with Caregiver (CG) to conduct a 10 day investigation visit regarding the allegations listed above.
On today's visit, at 12:42pm, LPA Quiroz reviewed 3 of 3 medication records for Resident 1 (R1), Resident 2 (R2) and Resident 3 (R3). Three of three medication records were found to be within Title 22 California Code Of Regulations (CCR). Therefore based on the preponderene of evidence gathered the allegation of "Facility administering medications to residents without an authorized physician's request" is deemed UNFOUNDED. This agency has investigated the allegation, which has been found to be Unfounded; meaning the allegation was false, could not have happened or/is without a reasonable basis. Therefore, the allegations is dismissed.
At 1:45pm, LPA Quiroz reviewed personnel report LIC 500, which reflects Administrators Cynthia Tadeo and Geisel Sanchez are on premises required amount of hours per Title 22 CCR.

***Continued on next page***

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2020

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

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 22-AS-20200214075808

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: SERENE SENIOR CARE	FACILITY NUMBER: 306005294
	VISIT DATE: 02/20/2020

NARRATIVE

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During the course of the investigation, LPA Quiroz conducted interviews with 4 of 4 interviewees, reviewed documents including but not limited to LIC 500 Personnel Report dated 2/20/2020, which reflects Administrator Tadeo and Administrator Sanchez are present at facility required amount of hours per Title 22 CCR.
Therefore based on the preponderance of evidence gathered the allegation of "Administrator not in the facility sufficient amount of hours" is deemed UNFOUNDED. This agency has investigated the allegation, which has been found to be Unfounded; meaning the allegation was false, could not have happened or/is without a reasonable basis. Therefore, the allegation is dismissed.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2020

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 22-AS-20200214075808

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: SERENE SENIOR CARE	FACILITY NUMBER: 306005294
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/20/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/27/2020 Section Cited CCR 80087(a)	1 2 3 4 5 6 7	80087(a):Buildings and Grounds -(a)The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator Cynthia Tadeo will submit proof of receipt from Electrician regarding electrical outlet repairs and pertinent receipts related to sliding door and screen by POC due date of 2/27/2020.
	8 9 10 11 12 13 14	Based on observations and interviews, at Between 12:02-12:14pm LPA Quiroz observed two (2) outlets in shared bedroom and two (2) outlets in shared bathroom with no electrical power, broken backyard sliding door, and damaged screen in sliding door. *Continued on next page*	8 9 10 11 12 13 14	Continued...This was verified with Administrator Cynthia Tadeo who reported "Yes, I'm going to have someone come out and repair everything." This poses a potential risk for residents in care.
	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: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2020

LIC9099 (FAS) - (06/04)

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