306005410-2-2-2023-22-AS-LADS-CNTRE4-20230207115655

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005410
Report Date: 02/02/2023
Date Signed: 02/02/2023 11:20:43 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
01/26/2023 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230126151748

FACILITY NAME:	SERENTO ROSA		FACILITY NUMBER:	306005410
ADMINISTRATOR:	SHANNON HUNDLEY		FACILITY TYPE:	741
ADDRESS:	17803 IMPERIAL HIGHWAY		TELEPHONE:	(714) 777-9666
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY:	135	CENSUS: 43	DATE:	02/02/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Hrag Bekerian		TIME COMPLETED:	11:35 AM

ALLEGATION(S):

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-Facility is not reporting new COVID-19 positive cases to residents, resident's responsible party and Community Care Licensing Department.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jerome Haley made unannouced visit to intiatate the investigation for the complaint received against this facility on January 26, 2023. LPA Haley was allowed into the facility and explaind the reason for the visit upon entry. LPA Haley discussed the complaint allegation with Senior Execurtive Director (ED) Hrag Bekerian.

Regarding the allegation: Facility is not reporting new COVID-19 positive cases to residents, resident's responsible party and Community Care Licensing Department.

On January 24, 2023, LPA Haley was present at Serento Rosa delivering findings on complaint control # 22-AS-20220927123807. During the visit LPA Haley was verbally informed by Execuritve Director (ED) Shannon Hundley there were COVID positive cases in the facility. Due to the recent outbreak in the facility, the dining room was closed and meals were being delivered to the residents.
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: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

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-20230126151748

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: 02/02/2023

NARRATIVE

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LPA Haley asked ED Hundley if the cases were reported, and he stated the new cases were reported to the health department. LPA Haley informed ED Hundley the department (CCLD) needs to be notified as well every time there's a new positive case at the facility. ED Hundley was not familiar with the COVID script used by the regional office, so LPA Haley email a blank COVID script to ED Hundley January 24, 2023. On January 27, 2023, ED Hundley returned the completed COVID script.

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: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

LIC9099 (FAS) - (06/04)

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