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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803720
Report Date: 06/28/2024
Date Signed: 06/28/2024 03:07:43 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
04/10/2024 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20240410150612
FACILITY NAME:SERENITY VILLA IIFACILITY NUMBER:
496803720
ADMINISTRATOR:REZNIK, AIDAFACILITY TYPE:
740
ADDRESS:184 BOAS DRTELEPHONE:
(415) 609-3827
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:12CENSUS: 11DATE:
06/28/2024
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:CaregiverTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Staff verbally abusing resident
INVESTIGATION FINDINGS:
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At approximately 1:00pm, Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to deliver findings regarding the above allegations and met with caregiver. Aida Reznik, Administrator contacted by phone and gave permission for caregiver to sign.

Complaint alleges staff verbally abusing resident. Three [3] out of five [5] interviews with residents indicate that they have never been yelled at by a staff member; one (1) resident reported that they heard yelling, but it was more like talking loudly. Resident reports that no one has ever yelled at them. One (1) resident reported that they were yelled at, but that staff member no longer works here. The involved staff denies yelling. LPA did not observe any yelling by staff. However, LPA interviewed 3 out of 7 staff and each staff stated they have heard staff yell at residents. Based on LPA's observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, are being cited on the attached LIC 9099D.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2024
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 4
Control Number 21-AS-20240410150612
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SERENITY VILLA II
FACILITY NUMBER: 496803720
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/01/2024
Section Cited
CCR
87468.1(a)(1)
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Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
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Facility has terminated staff found to have yelled at residents. Deficiency cleared.
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This requirement is not met as evidenced by:
Based on LPA interviews, the licensee did not comply with the section cited above in that facility staff was observed to have yelled at residents, which poses an immediate health, safety or personal rights risk to persons 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: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
04/10/2024 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20240410150612

FACILITY NAME:SERENITY VILLA IIFACILITY NUMBER:
496803720
ADMINISTRATOR:REZNIK, AIDAFACILITY TYPE:
740
ADDRESS:184 BOAS DRTELEPHONE:
(415) 609-3827
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:12CENSUS: 11DATE:
06/28/2024
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:CaregiverTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Resident does not receive required medication
Facility is not meeting resident's care needs
INVESTIGATION FINDINGS:
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At approximately 1:00pm, Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to deliver findings regarding the above allegations and met with caregiver. Aida Reznik, Administrator contacted by phone and gave permission for caregiver to sign.

Complaint alleges resident does not receive required medication. Interviews with five [5] out of eleven [11] residents indicated that residents do get their medication and that they have never missed any, that they know of. Facility does not use a Medication Administration Record (MAR) but sends an Incident Report when a resident refuses medication. Review of Incident Reports received from facility since January 2024 does not show any refused medication by residents. LPA also spot checked medication for three (3) of eleven (11) residents, medications were counted and the correct amount of pills were in the medication bottles observed. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated.

Continued on 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2024
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 4
Control Number 21-AS-20240410150612
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SERENITY VILLA II
FACILITY NUMBER: 496803720
VISIT DATE: 06/28/2024
NARRATIVE
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Continued from 9099A...

Complaint alleges facility is not meeting resident's care needs. Per review of records, resident was admitted to facility 2/20/2024 during a transitional time regarding their healthcare team. There were multiple changes in the persons providing care or assigned to the resident’s healthcare team. Resident is pre-diabetic and requires a consistent controlled carbohydrate (CCHO) and mechanically soft diet. Resident is non-ambulatory and requires assistance with ADLs, with the exception the resident is able to feed themselves. Per record review, facility has monitored blood sugar of resident beginning the day after admittance. Interviews with staff indicate an initial lack of clarity by resident’s healthcare team in regards to what actions need be taken if the blood sugar is too high or too low. Licensee requested clarification from resident’s healthcare nurse and received instruction as of 3/23/2024. On 3/27/2024 licensee held training with staff and made a chart for them specific to resident, as to an action plan regarding blood sugar readings. Record review shows that the resident was to receive a shower or sponge bath on Tuesdays, and a shower on Fridays. Record review shows that resident refused showers on a regular basis. Resident is not ambulatory and works with physical therapy to regain ambulatory status. Per interviews with staff and outside party, resident is often resistant to physical therapist’s suggestions for activity. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4