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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803610
Report Date: 12/17/2024
Date Signed: 12/17/2024 02:51:56 PM

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
10/15/2024 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20241015114030
FACILITY NAME:SERENITY VILLAFACILITY NUMBER:
496803610
ADMINISTRATOR:REZNIK, AIDAFACILITY TYPE:
740
ADDRESS:477 PETALUMA AVENUETELEPHONE:
(415) 609-3827
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY:25CENSUS: 24DATE:
12/17/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:German Sinitsyn (Licensee)TIME COMPLETED:
03:05 PM
ALLEGATION(S):
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-Facility is not following resident's special diet.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Licensee German Sinitsyn.

The Department received an allegation of facility is not following resident’s special diet. Per Reporting party, staff report to Licensee that an unknown resident had a recent modification of diet texture (puree) due to potential choking incident, which was then disregarded by the licensee, who permitted staff to provide the resident with a food outside of their diet texture recommendation/order. In addition, there has been a lack of follow-through with diet texture recommendations and education to staff regarding safe and unsafe foods for resident (R1) and another resident (name unknown) where staff have expressed that they "use their best judgement", thereover putting the residents at risk of aspiration, choking, and/or death by not supervising residents during their mealtimes.
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: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
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 21-AS-20241015114030
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: 12/17/2024
NARRATIVE
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Continued from LIC9099...

During the course of investigation, LPA conducted 10-day visit on 10/17/24, made observations and conducted interviews. Based on observations, there was a menu posted on the wall with food options, there were signs including high aspiration risk foods to avoid (rice, bread, baked goods, corn, hot dogs, sausages, all raw fruits/vegetables, dry and tough meats needed to be soft, cut into ¼” pieces with added moisture, etc. Foods allowed for mechanical soft diets, also known as “diced” or “chopped”. Reminders of food allergy with names of residents, four groups of staff assigned to assist residents during morning and afternoon meals. Based on records review of resident’s physician reports 10 out of 21 residents do have special diets on file. Resident’s (R1) initial prescribed diet texture dated 9/25/24 recommends as Puree, soft, bite-sized, nectar thick liquids; but according to the reporting party the facility provided R1 with regular solids and thin liquids. Then, R1’s diet texture was re-assessed on 9/26/24 and they were upgraded and recommended mechanical soft solids, nectar thick liquids. Staff training records indicates that staff have received required training hours regarding food management including assistance with feeding the residents. The facility provided LPA with the last four weeks’ menu served to residents, which appears to be appropriate for residents with special diet orders. Based on confidential interviews conducted with witness, staff, and residents. LPA have contacted the reporting party on 10/16/24, who confirmed their concerns regarding staff not following resident’s special diet due to a lack of training or education regarding caring for individuals with swallowing disorders and not adhering to recommendations for modified diet textures and liquid consistencies. According to the reporting party, the licensee refused training about food preparation of mechanically altered solids and thickened liquids offered by an outside agency due to their impression that food options and management is perceived as adequate for residents in care. Per staff (S1, S2, S3, S4, S5 & S6) they are informed by their supervisors when a resident’s diet has changes, also they do review signs posted on the kitchen’s wall instructing them about resident’s orders, allergies and assistance needed with their food. According to staff, residents are being offered with different food options to meet their preferences, their weekly menus are rotated every week, and staff did not recall any incident where a resident have chocked due to been provided with the wrong meal option. Interviews conducted with residents (R1, R2, R3, R4, R5 & R6) did not reveal any concerns, challenges or incidents with the food service provided by the facility. A finding that the complaint allegation occurs of facility is not following resident’s special diet is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations 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: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC9099 (FAS) - (06/04)
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