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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435294193
Report Date: 03/11/2025
Date Signed: 03/11/2025 12:59:15 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/29/2025 and conducted by Evaluator Kiran Jain
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20250129132020
FACILITY NAME:EL SERENO HOMEFACILITY NUMBER:
435294193
ADMINISTRATOR:CARR, THERESA R.FACILITY TYPE:
740
ADDRESS:2080 EL SERENO AVENUETELEPHONE:
(650) 968-8400
CITY:LOS ALTOSSTATE: CAZIP CODE:
94024
CAPACITY:6CENSUS: 6DATE:
03/11/2025
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Ofelia Guanzon, Assistant AdministratorTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Facility did not refund of former resident’s paid rent for December 2024
INVESTIGATION FINDINGS:
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On March 11, 2025, at 12:15 PM, Licensing Program Analyst (LPA) Kiran Jain arrived at the facility to conduct a Complaint Investigation visit. Upon arrival, the LPA was greeted by the Assistant Administrator (AAD) Ofelia Guanzon. The LPA disclosed the purpose of the inspection. The AAD informed the LPA that there were six (6) residents in care.

Regarding the allegation “Facility did not refund the former resident’s paid rent for December 2024”, the Reporting Party (RP) stated “resident (R1) passed away on 12/2/2024. RP stated they moved out all R1's belongings from the facility on 12/3/2024. RP stated based on R1's admission agreement/termination agreement, the facility shall return 27 days of R1's December 2024 monthly rent. RP stated R1's December 2024 monthly rent is $7665.00. RP stated she talked to Administrator Theresa Carr (ADM) several times, but ADM only agreed to refund 16 days of R1's December 2024 monthly rent. RP stated they haven’t received any refund from the facility yet.”

Continued on LIC9099-C
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
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 26-AS-20250129132020
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: EL SERENO HOME
FACILITY NUMBER: 435294193
VISIT DATE: 03/11/2025
NARRATIVE
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On March 5, 2025, LPA interviewed Assistant Administrator (AAD) Ofelia Guanzon. AAD confirmed that R1 passed away on December 2, 2024, and that R1’s family member (FM1) picked up R1’s belongings on December 3, 2024. AAD also stated that R1’s hospice bed was removed from the facility on the same day. According to AAD, the facility issued a refund check on February 24, 2025, for the amount of $6,909.00, and FM1 picked up the check on March 1, 2025.

On March 5, 2025, LPA attempted to contact FM1 by calling both their cell phone and home phone numbers, leaving voicemails requesting a callback. Follow-up calls were made to FM1’s home phone on March 6, 2025, March 7, 2025, and March 10, 2025, with additional voicemails left requesting a response.

On March 10, 2025, LPA reviewed R1’s admission agreement, which indicated the termination of agreement upon the death of the resident and when all personal belongings are taken out by the family from the room. LPA reviewed R1’s death report, which confirmed that R1 was on hospice care and passed away on December 2, 2024. LPA also reviewed R1’s hospice discharge summary, which indicated that the last hospice visit occurred on December 2, 2024. Additionally, LPA examined documents received from the facility, which confirmed that a refund check for $6,909.00 was issued on February 24, 2025, and that FM1 picked up the check on March 1, 2025.

Based on the interviews conducted and records reviewed, the department has determined that the allegation is false, could not have happened, and/or is without a reasonable basis. Therefore, the allegation is UNFOUNDED.

No deficiencies were cited under the California Code of Regulations, Title 22.

An exit interview was conducted with the Assistant Administrator. A copy of this report was discussed and left with the Assistant Administrator, Ofelia Guanzon, whose signature on this form confirms receipt of this report.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2