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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803610
Report Date: 03/04/2025
Date Signed: 03/04/2025 02:09:24 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
12/09/2024 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20241209155517
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: 16DATE:
03/04/2025
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Maritza Pray (Back up Administrator)TIME COMPLETED:
02:24 PM
ALLEGATION(S):
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-Lack of supervision.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Cuadra and Contreras arrived unannounced to deliver findings regarding the above allegation and met with Maritza Pray (Back up Administrator).

The Department received an allegation of lack of supervision. Per Reporting party on 12/13/24 resident (R1) fell out of bed during the night and were left there for hours until shift change came in the morning for assistance. R1 was observed with a visible bruising on left arm. On 12/2/24 resident (R2) waited for long time for assistance (no specific time was provided) R2 was observed with bruising on upper left head and wrist. Based on interviews conducted with staff (S1, S2, S3 & S4), they indicated that there are residents including R1 and R2 who usually do not sleep during the night and their protocol includes keeping an eye on them, offer them food or walk with them. The Department received a self-report notifying that R1 fell out of their bed and was transported to the hospital for further evaluation and did not return to the facility.

Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
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 21-AS-20241209155517
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: 03/04/2025
NARRATIVE
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Continued from LIC9099...

Regarding call system staff indicated that the process consists in the alarm located in the hallway by the medication room will alert the staff that a resident needs assistance, the device will state the room number that needs assistance, when the residents pull their alarm pendant that it is usually maintained on their neck, which it was confirmed by residents (R3 & R4) interviewed by LPA; Then the staff who will assist the resident will turn off the alarm and will go help the resident. Although, staff revealed that call responses are not documented by the facility, they ensured that they are responding timely to calls from residents in care. During interviews with staff, LPA learned that R1 had a tendency to pull their pendant and when staff arrives to their room, they will pretend like if they were sleeping. Residents interviewed by LPA stated that they are been assisted by staff when needed and they were able to locate their pendant when they need to call staff for assistance. LPA attempted to speak with R1, but they are no longer residing at the facility. R2 refused to talk with LPA. Based on records review, the facility documents medication, care, get out of bed and food services refusal in a log created by the facility, LPA was provided with log for the month of December 2024 and January 2025, where it was confirmed that both residents tend to refuse services and care provided by the staff. Resident’s (R1 and R2) physician report confirms that they need assistance with self-care including bathing and dressing. Although, LPA reviewed personnel report (LIC500) and timesheets for the month of December 2024 did not indicate any supportive evidence that there was a lack of supervision to residents in care. LPA is unable to determine if there had been any time when staff did not respond to resident’s calls at any prior date. A finding that the complaint allegation occurs of lack of supervision 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.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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