306005410-1-24-2023-22-AS-LADS-CNFMG9-20230126083535

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005410
Report Date: 01/24/2023
Date Signed: 01/24/2023 10:43:32 AM

Unsubstantiated

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
09/27/2022 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220927123807

FACILITY NAME:	SERENTO ROSA		FACILITY NUMBER:	306005410
ADMINISTRATOR:	CHONDALA YANGUBA		FACILITY TYPE:	741
ADDRESS:	17803 IMPERIAL HIGHWAY		TELEPHONE:	(714) 777-9666
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY:	135	CENSUS: 59	DATE:	01/24/2023
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Shannon Hundley		TIME COMPLETED:	09:50 AM

ALLEGATION(S):

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Facility staff failed to assist resident with wheelchair transfer, which led to an unnecessary fall.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to deliver findings on complaint control #: 22-AS-20220927123807. LPA Haley was granted entry by staff explained the reason for the visit. Executive Director (ED) Shannon Hundley was notified via telephone and arrived a short time later.

Regarding the allegation: Facility staff failed to assist resident with wheelchair transfer which led to an unnecessary fall.

The initial complaint visit was conducted September 30, 2022. Interviews with the Executive Director, 6 staff, and document review revealed the following:

On September 24, 2022 Resident 1 (R1) was found in her room on the floor by the NOC (night shift) shift staff around 5:45AM. At that time R1 had no visible injuries and no complaints of pain, so staff placed her back in the bed.
Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20220927123807

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: 01/24/2023

NARRATIVE

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About an hour later around 6:45AM a morning shift staff member entered R1’s room and according to staff there was vomit all over the bed and it smelled like feces. Staff attempted to contact the nurse at this time and while waiting on a response from the nurse the caregiver noticed a lump on the side of R1’s head, and staff decided to call the nurse again. According to interviews, caregivers were still attempting to contact the nurse at 8:38 AM via text message. The resident was found on the floor at 5:45AM and at 6:45AM the resident was found in her room with vomit all over the bed, the room smelled like feces, and the resident was observed with a lump on the side of her head. The nurse eventually arrived and R1 was sent to the hospital around 9:00 AM by Lynch non-emergency ambulance.

Based on the information gathered during the investigation, document review and interviews, the Department 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, and a copy of this report was provided.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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