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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005410
Report Date: 03/09/2021
Date Signed: 03/09/2021 04:45:29 PM



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
03/04/2021 and conducted by Evaluator Kathrina Chin
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20210304102027
FACILITY NAME:SERENTO ROSAFACILITY NUMBER:
306005410
ADMINISTRATOR:JEFFREY TOOMERFACILITY TYPE:
741
ADDRESS:17803 IMPERIAL HIGHWAYTELEPHONE:
(714) 777-9666
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:135CENSUS: 51DATE:
03/09/2021
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Dennis Robeniol, Health & Wellness Director/LVNTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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1) Staff abusing residents in care.
2) Residents are left in soiled diapers for a long period of time.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Kathrina Chin contacted the facility via telephone to commence a complaint investigation via telephone due to COVID-19 and for pre-cautionary measures. LPA Chin identified herself and spoke to Dennis Robeniol, Health & Wellness Director(HWD)/LVN. LPA discussed the purpose of the phone call and explained the allegations.

Dennis Robeniol, HWD LPA Chin spoke to Dennis Robeniol, HWD via Facetime. Mr. Robeniol reported that the two staff members mentioned in the complaint are both working in the skilled nursing facility and not in this assisted living facility. Based on the above findings, this allegation is deemed Unfounded.

This agency has investigated the complaint and is determined to be UNFOUNDED. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2021
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 2
Control Number 22-AS-20210304102027
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: 03/09/2021
NARRATIVE
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An exit teleconference was conducted with Dennis Robeniol and LPA Chin discussed and read this report. A copy of this report will be provided via email. Dennis Robeniol agreed to review the report and return a signed copy.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2