306005410-4-9-2021-22-AS-SSAS-C35V7Y-20210518161155

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005410
Report Date: 04/08/2021
Date Signed: 04/09/2021 09:06:15 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
09/25/2020 and conducted by Evaluator Kathrina Chin

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200925095614

FACILITY NAME:	SERENTO ROSA		FACILITY NUMBER:	306005410
ADMINISTRATOR:	JEFFREY TOOMER		FACILITY TYPE:	741
ADDRESS:	17803 IMPERIAL HIGHWAY		TELEPHONE:	(714) 777-9666
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY:	135	CENSUS: 51	DATE:	04/08/2021
		UNANNOUNCED	TIME BEGAN:	02:33 PM
MET WITH:	Liyon O'quinne, Executive Director		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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1) Resident room is not being cleaned.
2) Facility has expired food.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Kathrina Chin contacted the facility via telephone to conclude a complaint investigation via telephone due to COVID-19 and for pre-cautionary measures. LPA Chin identified herself and spoke to Liyon O'quinne, Executive Director and Dennis Robeniol, Health & Wellness Director/LVN. LPA discussed the purpose of the phone call and explained the allegations.

Allegation 1- Resident's room is not being cleaned.

LPA conducted an initial complaint investigation on September 28, 2021 and LPA met with Liyon O'quinne, Executive Director and Angie Penate, Care Coordinator. On that day, LPA Chin observed a large area in the carpet to be badly stained and the carpet was dirty in Room 225. LPA also observed rooms 220, 227, 223, 219 and 218 and these rooms were clean and had no issues regarding cleanliness. LPA also reviewed pictures provided to CCLD of Room 225 in which the carpet is dirty and badly stained in quite a large area of the carpet. The picture also showed the sink to be dirty. (Continued on LIC 9099C).

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina Chin	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2021

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-20200925095614

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: SERENTO ROSA	FACILITY NUMBER: 306005410
	VISIT DATE: 04/08/2021

NARRATIVE

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Based on the information obtained during the course of the investigation through interviews, observations and record review, a preponderance that was established to substantiate the allegation that the facility was in disrepair. See LIC 9099D for cited deficiencies per Title 22, Division 6 of the California Code of Regulations:

Allegation 2 - Facility has expired food. It was alleged that there was expired milk in R1's small refrigerator in Room 225.

Witness 1 (W1) provided a picture of the expired milk carton found in Room 225 in Resident's 1 (R1) room. Staff 1 was questioned about the expired milk carton in R1's small refrigerator and she was unaware that this has occurred.

Based on the information obtained during the course of the investigation through interviews, observations and record review, a preponderance that was established to substantiate the allegation that the facility has expired food.

See LIC 9099D for cited deficiencies per Title 22, Division 6 of the California Code of Regulations

An exit teleconference was conducted with Liyon O'quinne, Executive Director and LPA Chin discussed and read this report. A copy of this report will be provided via email along with the appeal rights. Ms. O'quinne agreed to confirm the receipt of the document, review the report and return a signed copy.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina Chin	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 22-AS-20200925095614

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: SERENTO ROSA	FACILITY NUMBER: 306005410
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/08/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/15/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation-The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well being of residents, employees and visitors. This requirement is not met as evidenced by the observation and the picture provided to CCLD.	1 2 3 4 5 6 7	Liyon O'quinne, ED stated that she will submit a plan of correction within one week by 4/15/2021.
	8 9 10 11 12 13 14	The carpet in Room 225 had a large stain on the carpet and the sink was dirty. This poses a potential risk to the health & safety of residents in care.	8 9 10 11 12 13 14
Type B 04/15/2021 Section Cited CCR 80076(a)(1)(A)(7)	1 2 3 4 5 6 7	(7) Commercial foods shall be approved by appropriate federal, state, and local(7) Food Services - Commercial foods shall be approve All foods shall be selected, transported, stored, prepared and served to be free from contamination and spoilage and shall be fit for human consumption. Food in damaged containers shall not be accepted, used or retained	1 2 3 4 5 6 7	By POC due date of 4/15/2021, the Administrator agrees to conduct an in-service training to all care staff. As a proof of correction, the Administrator agrees to submit to CCLD the proof of training signed and dated by the staff who participated in the training.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by the picture provided to CCLD, the picture shows that the milk expired on 7/24/2020 and picture was taken on 9/27/2020. This is poses a potential risk to the health & safety of the residents in care.	8 9 10 11 12 13 14

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: Sheila Santos	TELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina Chin	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2021

LIC9099 (FAS) - (06/04)

Page: 3 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
09/25/2020 and conducted by Evaluator Kathrina Chin

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200925095614

FACILITY NAME:	SERENTO ROSA		FACILITY NUMBER:	306005410
ADMINISTRATOR:	JEFFREY TOOMER		FACILITY TYPE:	741
ADDRESS:	17803 IMPERIAL HIGHWAY		TELEPHONE:	(714) 777-9666
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY:	135	CENSUS: 48	DATE:	04/08/2021
		UNANNOUNCED	TIME BEGAN:	02:33 PM
MET WITH:	Liyon O'quinne, Executive Director		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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5
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9

The facility has insufficient staff necessary to meet the needs of the residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Kathrina Chin contacted the facility via telephone for the purpose of presenting the findings of the complaint investigation due to COVID-19 and pre-cautionary measures. LPA Chin identified herself and discussed the findings with Liyon O'quinne, Executive Director.

On September 28, 2020, Angie Penate, Care Coordinator at that time provided a tour of the facility via Facetime to LPA Chin and showed all the employees that were working at the facility on that day and observed that there were sufficient staff in all departments. LPA interviewed Liyon O'quinne, Executive Director and two staff persons on the same day. S2, S3, and S4 indicated that there is sufficient staff to provide to residents. LPA Chin reviewed LIC 500 Personnel/Staff Schedules provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina Chin	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2021

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 5

Control Number 22-AS-20200925095614

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: SERENTO ROSA	FACILITY NUMBER: 306005410
	VISIT DATE: 04/08/2021

NARRATIVE

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LPA Chin interviewed resident 1 and resident 2. Both residents indicated that there is enough staff working at the facility.

The Department has investigated the complaint alleging that the facility has insufficient staff. Based on the information gathered during the investigation and review of all documents obtained, the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

An exit teleconference was conducted with Liyon O'quinne, Executive Director and LPA Chin discussed and read this report. A copy of this report will be provided via email along with the appeal rights. Ms. O'quinne agreed to confirm the receipt of the document, review the report and return a signed copy

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina Chin	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 5