496803610-3-28-2023-21-AS-CMAZ-CQDSWM-20230329141433

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803610
Report Date: 03/28/2023
Date Signed: 03/28/2023 09:04:10 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/09/2023 and conducted by Evaluator Marisol Cuadra

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20230209141814

FACILITY NAME:	SERENITY VILLA		FACILITY NUMBER:	496803610
ADMINISTRATOR:	REZNIK, AIDA		FACILITY TYPE:	740
ADDRESS:	477 PETALUMA AVENUE		TELEPHONE:	(415) 609-3827
CITY:	SEBASTOPOL	STATE: CA	ZIP CODE:	95472
CAPACITY:	21	CENSUS: 16	DATE:	03/28/2023
		UNANNOUNCED	TIME BEGAN:	08:23 AM
MET WITH:	Maritza Pray (Administrator)		TIME COMPLETED:	09:17 AM

ALLEGATION(S):

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Staff mismanaged resident medication
Staff did not adequately store medications
Staff not adequately trained to meet the needs of resident in care
Staff did not provide records to resident's authorized person

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cuadra arrived unannounced to the facility met with Maritza Pray, Administrator to deliver findings regarding the complaint allegation above.

Regarding allegation of Staff mismanaged resident medication. Reporting Party reported that the R1 was prescribed on 1/30/23 a long acting pill twice a day for pain and would continue to have morphine as needed. However, on 2/1/23 R1 was found in excruciating pain, moaning and could not hold still. When they inquired to staff, they were told that the facility had not received medication prescribed. Also, staff told them that they could not give the resident medication if they don’t ask for it. Based on records review R1 was prescribed with Morphine 100mg/5ml oral solution on 1/28/23 as needed every 4 hours/PRN, based on Centrally Stored Medication and Destruction (CSMD) log, the medication was received at the facility on 1/29/23. On 1/31/23 R1 was prescribed 1 tablet of Morphine 15mg every 4 hours as needed for pain. Based on facility records provided of CSMD log all doses of medications were listed on the facility medication records to have been dispensed as ordered by the resident's Physician.
Continues on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

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 3

Control Number 21-AS-20230209141814

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SERENITY VILLA	FACILITY NUMBER: 496803610
	VISIT DATE: 03/28/2023

NARRATIVE

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Continued from LIC9099...

A finding that the complaint allegations “Staff mismanaged resident medication” is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation stating Staff did not adequately store medications. It was alleged that medication was observed by Reporting Party sitting on R1’s couch at the facility. LPA conducted confidential interviews with witnesses including hospice agency nurses that were conducting consistent visits to the facility who expressed that they did not observed any issues with medications storing, there were no concerns or have observed R1 being uncomfortable nor complained about pain. Also, it was disclosed that R1 did not believe on medication treatments and was consistently refusing medications. Based on records review of incident report logs, R1 was consistently refusing medications and facility notified pertinent parties about it. LPA has determined and confirmed that although R1’s baseline belief system was against medications, there was no indication that any dosage was missed or not stored properly by facility staff. A finding that the complaint allegations “Staff did not adequately store medications” is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Staff not adequately trained to meet the needs of resident in care. Per Reporting Party, they were told that the facility staff were not adequately trained to care for R1. Also, the staff did not know which resident’s records they could provide because the hospice agency oversaw medications. Based on observations of facility training records, LPA learned that the facility does onboard training of staff members. Based on records review, LPA confirmed staff medication training records are current. On 2/10/23 LPA conducted 10-day visit and observed sufficient staff members at the facility. A finding that the complaint allegations “Staff not adequately trained to meet the needs of resident in care” is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Continues on LIC9099C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 21-AS-20230209141814

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SERENITY VILLA	FACILITY NUMBER: 496803610
	VISIT DATE: 03/28/2023

NARRATIVE

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Continued from LIC9099C...

It was alleged that the facility did not provide resident’s records to responsible party. Per Reporting party alleged that facility staff was contacted by R1’s power of attorney (POA) to request R1’s medication records and staff told them that they could not provide records because they did not know which documents they could provide because the hospice agency was in charge of R1’s medication records. Based on records review, on 2/10/23 facility provided electronic communication records to LPA dated 2/9/23 at 4:47pm from R1’s responsible party requesting R1’s invoices and health care directive. On 2/9/23 at 7:39pm, facility responded to their request email, providing them with two pdf files including R1’s hospice file and pre-hospice medications, one is R1’s medication changes and the body of the email indicating them that the facility have sent to their accountants to provide them with monthly invoices. On 2/10/23 at 12:42pm the facility provided R1’s responsible party via email R1’s invoices since R1 was admitted to the facility. Based on confidential interviews, LPA was informed by facility and responsible party that records requested were released to R1’s responsible party as of 2/10/2023. Based on information received by the Licensee and reporting party, it was confirmed that records were provided to R1’s responsible party. A finding that the complaint allegation “Staff did not provide records to resident's authorized person” is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies cited during today’s visit.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

LIC9099 (FAS) - (06/04)

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