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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347003297
Report Date: 06/25/2025
Date Signed: 06/25/2025 11:56:19 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/20/2025 and conducted by Evaluator Kevin Mknelly
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20250620094344
FACILITY NAME:LA SERENA HOUSEFACILITY NUMBER:
347003297
ADMINISTRATOR:BRIONES, AIDAFACILITY TYPE:
740
ADDRESS:8970 LA SERENA DRIVETELEPHONE:
(916) 966-0865
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 5DATE:
06/25/2025
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Aida BrionesTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility staff mismanaged resident's medications
INVESTIGATION FINDINGS:
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 On June 25, 2025 (6/25/24), Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility and met with Licensee, Aida Briones, to open an investigation into the complaint allegation listed above.
During the investigation, the Department reviewed documentation pertinent to the investigation (CSMR and MARs) and received statements from additional parties involved in the R1’s care services.

The results of the investigation are as follows: LPA Michael Hood received Centrally Stored Medication Form (CSMF) and Mediation Administration Record (MAR) for resident (R1). LPA reviewed R1’s CSMF and MAR and observed discrepancies between records for at least five (5) of R1’s medications.
LPAs also reviewed a statement from hospice stating R1’s medications have not been managed and administered as ordered.
Based on records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page.
Exit interview was conducted. A copy of this report and appeal rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2025
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 59-AS-20250620094344
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LA SERENA HOUSE
FACILITY NUMBER: 347003297
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/26/2025
Section Cited
CCR
87465(a)(4)
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 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility (...) by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.
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Facility will complete a statement of understanding regarding regulation 87465 as well as the procedure for intake, recording and auditing medication records. Facility will submit statement to the Department by POC due date of 6/26/25.
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This requirement is not met as evidenced by:
Based on records reviewed and statement, the facility did not ensure that resident R1 was receiving medications as prescribed, which poses an immediate health, safety, and personal rights 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.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2