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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005410
Report Date: 01/24/2023
Date Signed: 01/24/2023 10:44:58 AM


Document Has Been Signed on 01/24/2023 10:44 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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



FACILITY NAME:SERENTO ROSAFACILITY NUMBER:
306005410
ADMINISTRATOR:SHANNON HUNDLEYFACILITY TYPE:
741
ADDRESS:17803 IMPERIAL HIGHWAYTELEPHONE:
(714) 777-9666
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:135CENSUS: 59DATE:
01/24/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:51 AM
MET WITH:Shannon Hundley TIME COMPLETED:
10:55 AM
NARRATIVE
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Licensing Program Analyst (LPA) Jerome Haley met with Executive Director (ED) Shannon Hundley during a case management visit to discuss information that was revealed during the investigation into complaint control #: 22-AS-20220927123807.

During the investigation it was discovered that Resident 1 (R1) was found on the floor in her bedroom around 5:45AM and was not sent to the hospital until around 9:00AM. As early as an hour later (6:45AM) staff noticed an injury to R1’s head and observed signs R1s health and safety was clearly in jeopardy. Several staff were aware of R1s fall, R1s condition: pale, shaking, vomiting (multiple times), and feces. After observing R1s condition, 911 was not contacted. Multiple staff contacted Staff 8 (S8) rather than call 911 when it was clear R1 needed medical attention. It is unclear if staff failed to contact emergency services because of what they were instructed to do (not call 911), incompetence, inexperience, or miscommunication. However, it was very clear R1 needed emergency medical attention and staff failed to get R1 that attention in a timely manner.

At the beginning of the case management visit, ED Hundley led a LPA Haley on a brief tour of the facility. During the brief tour, LPA Haley observed the kitchen, facility menu, facility supply of PPE, and residents in memory care were observed in a cooking class.

As a result of todays visit, deficiencies are being cited under California Code of regulations, Tittle 22, Division 6, Chapter 8.

An exit interview was conducted, and a copy of this report, and appeal rights were provided to ED Hundley.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/24/2023 10:44 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/24/2023
Section Cited

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87465 (g) Incidential Medical and Dental Care

The licensee shall immediately telephone 9-1-1 if an injury or other circumstances... but not limited to, an apparent lief threatning medical crisis except as specificed in Section 87469(c)(2), (c)(3), or (c)(4).
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LIcensee stated all staff have been trained on the importance of contacting 9-1-1 if a resident is injured. ED Hundley eill provide LPA Haley a copy of a all employees who attended the training by the POC due date: January 27, 2023.
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This requirement is not being met as evidenced by: On September 24, 2022 facility staff failed to 911 after discovering the resident had fallen and sustained a head injury. This poses an immediate health and safety risk to residents in care.
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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: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2023
LIC809 (FAS) - (06/04)
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