Serenity Senior Retreat

Allegation investigated: Staff leave residents unattended. Staff yells at residents.

Licensing Program Analysts (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to investigate the above allegations. LPA met with the administrator, Errol Fernando, and discussed the reason for the visit. --- Staff leave residents unattended. It was alleged that staff leave the residents unsupervised. To investigate the allegation, on 01/17/2022, LPA conducted a physical plant tour at around 3:10 PM, interviewed three (03) staff and two (02) out of four (04) residents between 3:40 PM to 4:40 PM. On 01/18/2022 at around 3:00pm, LPA interviewed the Reporting Party. On 02/01/2022 at 1:45 PM, LPA interviewed two (02) additional staff. During the physical plant tour, LPA observed three staff present in the facility. During interviews with Staff #1 (S1), Staff #2 (S2), Staff #3 (S3), Staff #4 (S4) and Staff #5 (S5), they all stated that they do not leave residents unsupervised. (cont. on LIC 9099-C) Unsubstantiated During interviews with residents, Resident #1 (R1) stated that staff do not leave residents unattended, Resident #2 (R2) was incoherent and LPA was unable to interview Residents #3 (R3) and #4 (R4). During an interview with the Reporting Party (RP), they stated that they don't know anything and hung up the phone. Subsequently, LPA made several attempts to reach the RP but to no avail. Based on observations and interviews, there is not enough information to verify the allegation, therefore, the allegation is unsubstantiated at this time. --- Staff yells at residents. It was alleged that staff yells at residents. To investigate the allegation, on 01/17/2022, LPA conducted a physical plant tour at around 3:10 PM, interviewed three (03) staff and two (02) out of four (04) residents between 3:40 PM to 4:40 PM. On 01/18/2022 at around 3:00pm, LPA interviewed the Reporting Party. On 02/01/2022 at 1:45 PM, LPA interviewed two (02) additional staff. During interviews with S1, S2, S3, S4 and S5, they all stated that they do not yell at residents. During interviews with residents, R1 stated that staff do not yell at residents, R2 was incoherent and LPA was unable to interview R3 and R4. During an interview with the Reporting Party (RP), they stated that they don't know anything and hung up the phone. Subsequently, LPA made several attempts to reach the RP but to no avail. Based on observations and interviews, there is not enough information to verify the allegation, therefore, the allegation is unsubstantiated at this time. No health and safety hazards noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Feb 1, 2023 · control 31-AS-20230117093943

Allegation investigated: Resident sustained a urinary tract infection while in care. Staff did not seek medical attention in a timely manner.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility. LPA met with Errol Fernando and explained the reason for the visit. ---Resident sustained a urinary tract infection while in care. It was alleged that Resident #1 (R1) sustained a bladder infection while in care. To investigate this allegation, on 08/27/2022 at 11:30 AM, LPA interviewed two (02) staff, on 08/27/2022 at 01:30 PM, LPA conducted a record review and, on 09/17/2022 at 10:30 AM - 11:30 AM, LPA interviewed with the facility’s Administrator and R1's responsible party. Interviews and record reviews revealed that although R1 sustained a bladder infection while in care, R1 was admitted to the facility with prior health conditions, most notably, recurring urinary tract infections. There is a lack of substantial evidence that the resident sustained the infection due to the neglect in care and supervision. Based on interviews and record review, there is not enough information to verify the allegation, therefore, the allegation is UNSUBSTANTIATED at this time. (Cont. on LIC9099-C) Unsubstantiated --- Staff did not seek medical attention in a timely manner. It was alleged that staff did not seek medical attention timely. To investigate this allegation, on 08/27/2022 at 11:30 AM, LPA interviewed two (02) staff, on 08/27/2022 at 01:30 PM, LPA conducted a record review and, on 09/17/2022 at 10:30 – 11:30 AM, LPA interviewed the Administrator and R1’s responsible party. During interviews, the responsible party stated that R1 had bloody discharge and was unable to communicate with R1 effectively as R1 was in a mental state of confusion. In contrast, the Administrator stated that R1 did not have a change in mental state and was able to communicate with others very well but did agree that R1 had bloody discharge. Furthermore, interviews and record reviews revealed that although R1 had bloody discharge, R1 used a urinary catheter which can cause small bleeding as the catheter tube passes along the lining of the urethra. At this time, there is a lack of substantial evidence that there were changes in R1’s health condition prior to the responsible party seeking medical attention and receiving a diagnosis. Based on interviews and record review, there is not enough information to verify the allegation, therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards observed during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Sep 17, 2022 · control 31-AS-20210210133214

Allegation investigated: Staff are mistreating residents

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent visit to this facility to further investigate the above allegation. LPA met with staff Glenda Dulay who called the administrator Eddie Provost and explained the reason for the visit. Ms. Provost arrived twenty (20) minutes later. LPA conducted physical plant tour at 11:15 AM, requested copy of facility documents relevant to the investigation at 11:45 AM and interviewed additional staff and residents between 12:10 PM to 2:00 PM. Regarding the allegation that staff are mistreating residents, it was alleged that residents at the facility are being mistreated by the staff. LPA's interview with residents on 07/27/22 at around 1:20 PM and today at 12:30 PM revealed that all four (4) residents interviewed did not experience being mistreated by anyone at the facility. All four (4) residents interviewed revealed that the staff are respectful and take care of all of their care needs. LPA's interview with staff on 07/27/22 at around 1:45 PM and today at 1:00 PM, also revealed that all three (3) staff denied mistreating any resident nor witnessed any staff mistreating any resident. (continued on LIC 9099-C) Unsubstantiated (continued from LIC 9099) Based on the information gathered during this and prior visit, there is no information to support the allegation and therefore deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Sep 7, 2022 · control 31-AS-20220721163345

Allegation investigated: Staff not properly reporting an incident regarding a resident. Staff do not communicate with authorized representative regarding the change of resident's health conditions.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility. LPA met with Errol Fernando and explained the reason for the visit. ---Staff not properly reporting an incident regarding a resident ---Staff do not communicate with authorized representative regarding the change of resident's health conditions. It was alleged that facility did not report an incident involving Resident #1 (R1). To investigate the above allegations, on 08/25/22 at 10:00AM, LPA reviewed facility’s file and, at 01:30PM, LPA reviewed the department’s records. On 09/17/22 at 10:30AM, LPA interviewed the administrator, Errol Fernando. Interviews and record review revealed that the facility did not submit an incident report after learning about R1’s change in health condition, the results from the doctor's visit and that the responsible party was not notified. Based on interviews and record reviews, the allegation is substantiated at this time. Pursuant to Title 22 Div.6 Ch.8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC9099-D): Exit interview was conducted, no health and safety hazards at this time. A copy of report was issued. (Cont on LIC9099-A) Substantiated Based on observations and interviews, there is not enough information to verify the allegation, therefore, the allegation is UNSUBSTANTIATED at this time. ---Staff are not following a resident's medical orders. It was alleged that staff would not take the resident’s blood pressure before administering medications. To investigate this allegation, on 08/27/2022, LPA conducted interviews with two (02) staff and five (05) out of five (05) residents from 11:30 AM – 01:15 PM. Interviews revealed that staff take the blood pressure of each resident prior to administering medication and that they do not refuse blood pressure measurement requests made by resident. Based on observations and interviews, there is not enough information to verify the allegation, therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards observed during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Aug 27, 2022 · control 31-AS-20210210133214

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Aug 31, 2022

87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency...:(1) A written report shall be submitted to the licensing agency of the occurrence of...(D) any incident which threatens the welfare, safety or health of any resident... This requirement is not met as evidenced by: Based on interviews & record reviews, the licensee did not comply with the section cited above as the facility did not notify the responsible party and send an incident report to the Dept. which poses a potential health & safety risk & violation of personal rights to residents in care.the state’s words, verbatim · CDSS document, Aug 27, 2022

Plan of correction: The Administrator will review Section 87211(a)(1)(D) and will inform in writing explaining how they will assure to follow Title 22 Regulations with regards to following reporting procedures.

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Abeye Duguma met with the Administrator, Jilska Parera for a One (1) Year Required - Infection Control visit for this facility. LPA explained the reason for the visit. A tour of the physical plant was conducted at 10:00am and the following was noted: There is one entrance being utilized at the facility, there are required posters posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing masks upon entrance and during the visit. Signs to wear masks and other COVID 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated outdoor visitors' area located in the backyard. The facility has sufficient stock of PPE in a cabinet near the dining area. The facility has a total of four (04) bedrooms, all utilized by residents and three (03) bathrooms for both residents and staff. The facility is fire cleared for one (01) bedridden and one (01) non-ambulatory in room #1, two (02) non-ambulatory in room #2, (01) non-ambulatory in room #3, one (01) ambulatory in room #4 and a hospice waiver for six (06). The facility is currently occupying five (05) residents of which four (04) arenon-ambulatory and under hospice care. The facility has outdoor furniture, with a covered shaded area for residents. The facility does not have a swimming pool/body of water. The garage is being used for storage. Laundry detergents, cleaning agents and other toxins are stored in a cabinet in the laundry room. Kitchen area was sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. (continued on LIC 809-C) Knives and sharps are observed to be locked in a drawer inaccessible to residents. Living and dining room furniture were also checked. The living room is neat and clean along with the dining room. The facility maintains a comfortable temperature at 74°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher is located in the kitchen nook, observed to be full and last purchased on 06/14/2021. The residents' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are well lit. Residents have enough personal hygiene product provided by the licensee and responsible parties. The bathrooms were checked for cleanliness and proper operations. The hot water temperature was measured at 118.8°F. Towels and washcloths are not shared. There was enough clean linen available in the master bedroom's walk-in closet. LPA observed medication and first aid kit to be locked and inaccessible to residents, located in a cabinet near the kitchen nook. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Dec 16, 2021