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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005410
Report Date: 02/08/2023
Date Signed: 02/08/2023 09:30:01 AM


Document Has Been Signed on 02/08/2023 09:30 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: 71DATE:
02/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Allan PerezTIME COMPLETED:
09:40 AM
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This unannounced case management inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following up on multiple self-reported incident reports received in the Orange County Regional Office (OCRO) on 02/03/23 regarding multiple falls involving Resident #1 (R1). LPA met with Wellness Director (WD) Allan Perez and discussed the purpose of the inspection. Administrator (AD) Shannon Hundley was not present during the inspection.

The incident reports state that: On 01/27/23 in the early morning, R1 had an unwitnessed fall, sustained a bruise to the head, was taken to the hospital, and returned in the morning that same day; on 01/27/23 in the afternoon, R1 had an unwitnessed fall, sustained a skin tear, was taken to the hospital, and returned the next day; on 01/28/23 in the early morning, R1 had a witnessed fall, sustained a closed head injury, was taken to the hospital, was temporarily relocated by family, and returned on 02/07/23.

During today’s inspection, LPA conducted a health and safety check on R1, observed R1 to be sleeping comfortably, and observed no health and safety issues. LPA interviewed WD who stated that R1 moved in on 01/03/23, that in addition to the 3 reported falls on 02/07/23 R1 had another witnessed fall, was taken to the hospital, and returned early the next day. WD stated that R1’s falls are caused by R1 not being compliant with a walker and trying to get up and go out on impulse without being physically able. WD stated that R1 is currently on the following fall precautions: fall mat, half bed rails, a low bed, checks every 30 minutes, and medical testing to rule out medical causes for the falls. In addition, the facility is working with R1’s doctor to start physical therapy and home health. Per WD, none of the 4 falls resulted in serious injuries or hospitalization. LPA reviewed R1’s Physician’s Report which states R1 has Dementia and multiple additional conditions and R1’s Pre-Placement Appraisal which identifies R1 as a fall risk. Per WD, an order for skilled nursing care was requested from R1’s doctor, but R1’s doctor decided R1 did not need skilled nursing care and instead ordered home health and physical therapy for R1.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2023
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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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
VISIT DATE: 02/08/2023
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WD stated that home health, physical therapy, and additional time to become acclimated to the community may help with the falls, but that if the falls continue then the facility may not be able to meet R1’s needs and would then discuss relocation with R1’s family.

Based on the information obtained during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
LIC809 (FAS) - (06/04)
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