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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803610
Report Date: 12/12/2023
Date Signed: 12/12/2023 02:39:30 PM

Substantiated


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
09/05/2023 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20230905113442
FACILITY NAME:SERENITY VILLAFACILITY NUMBER:
496803610
ADMINISTRATOR:REZNIK, AIDAFACILITY TYPE:
740
ADDRESS:477 PETALUMA AVENUETELEPHONE:
(415) 609-3827
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY:21CENSUS: 21DATE:
12/12/2023
UNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Erica Campos (staff)TIME COMPLETED:
02:54 PM
ALLEGATION(S):
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-Facility did not seek timely medical attention.
-Staff did not properly report an incident involving a resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cuadra arrived unannounced at the facility and met with staff Erica Campos to deliver findings regarding the complaint allegation above. Licensee Aida Reznik was not able to come to the facility, but was available by phone and gave authorization for staff to sign the report.

There was an allegation of facility did not seek timely medical attention. Per Reporting Party, resident’s (R1) sock with blood was observed by a witness, it was surprising that facility staff who assisted resident with daily activities did not discover the sore of considerable size and depth on their right foot sock. During this investigation, The Department investigator conducted interviews with staff and other witnesses, reviewed records associated to the involved R1. Based on interviews conducted and records obtained, the investigation revealed that on 7/29/23, the pressure ulcer on R1’s right heel was noticed by a witness. According to home health records, R1 received skilled nursing care from 5/4/23 through 8/9/23; Prior home health visits on 7/29/23 did not uncover a pressure ulcer.
Continued on LIC9099C...

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
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 5
Control Number 21-AS-20230905113442
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: 12/12/2023
NARRATIVE
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Continues from LIC9099...

Based on medical records dated 7/29/23 at 3:48:46pm responsible party contacted home health, which is indicated in the report that facility was aware of pressure injury. However, the facility did not seek timely medical from 7/29/23 until 8/7/23 when R1 met with their primary care physician through a virtual appointment and was diagnosed with a stage 2 pressure ulcer on their right heel. On 08/09/2023, R1 was assessed by hospice care staff and was diagnosed with a stage 2 pressure ulcer on their right heel. The Department obtained R1’s care plan dated 5/3/23 indicating that R1 needs assistance with daily activities including toileting, showering, and dressing. LPA conducted interviews with staff who informed LPA that they verbally notified responsible parties including home health agency about the blister that popped up from R1’s foot supposedly due to their socks that were assumed that were too tight. Facility failed to seek medical treatment when they noticed that the blister popped up to stage 2 pressure injury. Based on the information obtained by the Department during this investigation and confidential interviews conducted with witnesses, staff did not contact R1’s physician to seek timely medical attention after concerns about R1’s pressure injury. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. The Health and Safety Code is cited on the attached LIC 9099D. Appeal Rights Given. Failure to seek medical care resulted in violation causing injury to person in care $500 immediate civil penalty issued. The Department will be reviewing to determine if additional civil penalties are wanted.

Regarding allegation about staff did not properly report an incident involving a resident. Per reporting party, staff did not notify R1’s responsible parties including the Department about R1’s pressure injury. Based on records review, LPA reviewed incident report logs for this facility, and it was determined that incident reports were not submitted to CCL. Administrator could not provide proof that incidents were reported to CCL. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. The Health and Safety Code is cited on the attached LIC 9099D. Appeal Rights Given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
09/05/2023 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20230905113442

FACILITY NAME:SERENITY VILLAFACILITY NUMBER:
496803610
ADMINISTRATOR:REZNIK, AIDAFACILITY TYPE:
740
ADDRESS:477 PETALUMA AVENUETELEPHONE:
(415) 609-3827
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY:21CENSUS: 21DATE:
12/12/2023
UNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Erica Campos (staff)TIME COMPLETED:
02:54 PM
ALLEGATION(S):
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-Staff neglect resulted in a resident sustaining a pressure injury.
-Staff was sleeping during hours of care and supervision.
-Staff is unable to communicate effectively.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cuadra arrived unannounced at the facility and met with staff Erica Campos to deliver findings regarding the complaint allegation above. Licensee Aida Reznik was not able to come to the facility, but was available by phone and gave authorization for staff to sign the report.

There was an allegation of staff neglect resulted in a resident sustaining a pressure injury. Per Reporting Party, residents (R1) sustained a sore of considerable size and depth on their right foot sock. During this investigation, The Department investigator conducted interviews with staff and other witnesses, reviewed records associated to the involved R1. Based on interviews conducted and records obtained, the investigation revealed that on 7/30/23, the pressure ulcer on R1’s right heel was noticed by a witness. Based on records review, LPA learned through home health records, R1 was receiving skilled nursing care from 5/4/23 through 8/9/23 on average of two times per week for a different matter. In that time, R1 was never diagnosed with a pressure ulcer until 8/7/23.
Continued on LIC9099C...

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20230905113442
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: 12/12/2023
NARRATIVE
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Continued from LIC9099A...

LPA conducted interviews with staff who informed LPA that they noticed the blister that popped up from R1’s foot supposedly due to their socks that were probably too tight. Based on the information obtained by the Department during this investigation, facility staff were assisting R1 and there were no concerns raised regarding R1’s sustaining a pressure injury due to neglect of facility staff. Based on LPA’s confidential interviews conducted with witnesses, there is no supporting evidence to prove that staff neglect resulted in a resident sustaining a pressure injury. A finding that the complaint allegations staff neglect resulted in a resident sustaining a pressure injury 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 of staff was sleeping during hours of care and supervision. Per reporting party, on one occasion facility staff was observed asleep while R1 was watching the TV in bed. Based on Records review of facility schedule for the month of August 2023 indicates that caregivers who previously worked night shift will stay later in the morning to assist R1 with their care needs. On 11/9/23 LPA conducted interviews with facility staff and residents in care. Interviews revealed that R1 was receiving a higher level of care due to their aggressive and combative behavior, resuming services to one-on-one care. The caregiver who was their main companion will call another caregiver to help them to assist R1 with daily activities such toileting, showering, etc. However, there is no indication or supporting evidence that at any given time any facility staff was observed sleeping during business hours. A finding that the complaint allegation staff was sleeping during hours of care and supervision 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.

Another allegation is about staff is unable to communicate effectively. Per reporting party, the occasion when they observed staff sleeping during business hours, they attempted to talk to the caregiver, but the caregiver did not speak English. On 11/9/23 LPA conducted interviews with facility staff and residents in care. Per Administrator, staff are divided into groups of residents that will assist with care and supervision. Staff performances are based on family input of staff personalities. Administrator told LPA that there had been incidents where caregivers don’t communicate properly using the English level necessary to communicate with residents, then they will re-assign them to a different section. LPA was able to determine through interviews with facility staff and residents in care, that staff are able to communicate effectively in English when assisting residents in care. A finding that the complaint allegation staff is unable to communicate effectively 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.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20230905113442
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
12/13/2023
Section Cited
CCR
87466
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87466 Observation of the Resident - The licensee shall ensure that residents are regularly observed for changes in physical…& that appropriate assistance is provided when such observation reveals unmet needs...This requirement has not been met as evidence by:

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Administrator/Licensee agrees to submit a written plan in how staff will assess resident’s pressure injuries after a change of condition by POC due date. $500 immediate civil penalty
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Based on interviews conducted and records review. Facility did not observe change of condition in R1 after blister popped out of R1’s right foot, which poses an immediate risk to the health and safety of the residents in care.

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Request Denied
Type B
12/13/2023
Section Cited
CCR
87211(a)(1)(B)
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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require… (1) A written report shall be submitted to the licensing...& person responsible for the resident within 7 days…(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement has not been met as evidence by:
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The Licensee will ensure all incidents that threaten the safety of residents are reported to CCL per regulation. Administrator to review regulation, conduct staff training on reporting requirements.
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Based on LPA’s records review and interviews conducted Administrator did not ensure that CCL was notified of incidents involving R1’s Stage II pressure injury, which poses a potential health & safety risk to residents in care.

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Signed statement that the regulation was reviewed and sign in sheet for all staff trained to be submitted by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5