Mount Hood Serenity Care

Type of visit: Required - 1 Year

On 6/18/26, Licensing Program Analyst (LPA) Talwinder Bains arrived to conduct an annual inspection. LPA met with Licensee, Kevin Broomfield and explained the purpose of today's visit. There are no residents currently at the facility. LPA toured the facility together to ensure there are no residents. The areas toured included resident rooms, bathrooms, kitchen, and common areas and outside area. Grab bars were present at the toilet and in the shower. All exits were unobstructed. There is a side gate for emergency access. All required postings were observed. No deficiencies were observed or cited per Title 22, CCR Regulations during this visit. Exit interview conducted and copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 18, 2026

Type of visit: Office

On 01/27/26 at 1:30 PM, a virtual office meeting was held with Sacramento North Regional Office using Microsoft Teams. Present in the meeting were Community Care Licensing representatives: Licensing Program Manager (LPM), Laura Munoz; and Licensing Program Analyst (LPA), Talwinder Bains . Present in the meeting was Licensee, Kevin Broomfield. This meeting was to discuss the issue as department was notified on 01/26/26 via email by licensee that this facility will be closing. Licensee stated that they need more time to finalize facility closure and will get back with department with their decision. During today's meeting, department was informed by staff that facility already put the notifications to all residents, responsible parties and other required agencies regarding facility's closure. Facility will notify CCLD once all residents are moved out and/or for any other questions regarding this issue. No deficiencies were observed or cited during this meeting. An exit interview was conducted and copy of this report was provided to facility via email with request for return with signature.the state’s words, verbatim · CDSS document, Jan 27, 2026

Allegation investigated: Staff financially abused a resident in care.

On 06/11/25, Licensing Program Analyst (LPA) Talwinder Bains conducted complaint delivery visit and met with Administrator, Irene Nepomuceno and explained the purpose of the visit. Throughout the investigation the Department conducted interviews with staff, residents, key witness and reviewed documentation pertinent to the investigation. The results are as follows: ***Continuation on 9099-C*** Substantiated ***Report continued from 9099...... Allegation- Staff financially abused a resident in care. Department conducted staff and resident interviews and record review to investigate this allegation. On 05/28/2025, during department visit to the facility, law enforcement and resident, R1 and R1's family were present at the facility. Administrator advise RO staff that the facility learned that day (05/28/2025) that R1's family found checks written out to staff, S1 ($400) and a family member of S1 ($500) without the permission of the R1. R1 was interviewed and indicated they did not write the checks nor did give permission for S1 to write the checks to S1 or S1s family member. Record review reflected that both checks were cashed on 05/01/25 and 05/15/25 without R1s consent by S1 and S1s family. Administrator indicated they terminated S1 when they learned of the theft. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the allegation that staff financially abused a resident is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC-9099D. Appeal rights were provided. Exit interview was conducted and the report was provided to administrator.the state’s words, verbatim · CDSS document, Jun 11, 2025 · control 59-AS-20250529161737

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Jun 12, 2025

87468.2-Additional Personal Rights of Residents in Privately Operated Facilities(a) In addition to the rights listed in Section 87468.1....(8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidenced by; Record review and interviews reflected that resident, R1 funds were stolen by staff , S1 while living at the facility which poses a immediate health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Jun 11, 2025

Plan of correction: Licensee/administrator shall send a letter to the department for understanding of this regulation and shall conduct staff training. All POC documentation are due by 06/12/25.

Type of visit: Case Management - Other

On June 5, 2025, Licensing Program Analyst (LPA) Lavinia Muscan conducted an unannounced case management visit . This visit is to confirm ORDERS TO INDIVIDUAL FOR IMMEDIATE EXCLUSION FROM ALL FACILITIES. LPA met with Caregiver April Nepomuceno and stated the purpose of visit. Facility understands this is an Immediate Exclusion effective June 4, 2025 and S1 is excluded and cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services. Therefore, the Department orders the facility to remove S1 from any contact with clients and not allow this employee to be physically present in the facility. Exit interview conducted, a copy of this report provided on this date. A signature on these forms acknowledges receipt of these forms.the state’s words, verbatim · CDSS document, Jun 5, 2025

Type of visit: Office

On 05/29/25 at 03:00PM, an informal conference was conducted via Microsoft teams (virtual). The purpose of this informal conference meeting is to discuss issues which were identified during facility’s annual visit on 05/01/25 and case management visit on 05/28/25 and within last 3 years. Present in the meeting; Licensing Program Manager (LPM) Laura Munoz; Licensing Program Analysts (LPAs) Talwinder Bains and Lavinia Muscan; Licensee - Kevin Broomfield, and Administrator Irene Nepomuceno. The purpose of the informal conference is to have an open discussion related to the current issues at the facility. During this meeting the licensee was made aware that this Informal conference is a part of the Administrative Action process. The informal conference process was explained during this meeting. Issues discussed during the meeting were: · Issues related to Fire Clearance, uncleared staff working at the facility and medication accessibility, repeat deficiencies and other citations · Residents and staff Record not available for audits and incomplete record · Administrator’s qualifications To support the facility maintaining substantial compliance with Health and Safety Statute and Title 22 regulations, the Department is developing a plan with the licensee to address causes for concerns. Plan to address compliance concerns by 06/10/25: Submission of new LIC308, updated LIC500, Completing the pending POC requirements issued on 05/01/25, 05/28/25, plan to address how facility will be complying per Title 22 Regulations. Licensee/ Administrator was notified that the Department will provide additional case management visits and complete a referral to TSP (Technical Support Program). An exit interview was conducted. Copy of this report was provided via email and should be returned to department with signature within 24 hours.the state’s words, verbatim · CDSS document, May 29, 2025

Type of visit: Case Management - Other

On 05/28/25, Licensing Program Analysts (LPAs) Talwinder Bains and Lavinia Muscan arrived at the facility unannounced. LPAs met with Administrator Irene Nepomuceno and explained the purpose of the visit. LPAs conducted a case management visit to follow up on items after facility's visit from 05/01/25. : Department cited facility on 05/01/25 for staff, S1 was working at the facility on 05/01/25 and civil penalty of $500.00 was issued. Record review and staff interview indicated that facility allowed S1 to reside/present at facility after 05/01/25 which is a repeat violation 87355(e), therefore repeat citation was issued. Immediate civil penalty of $1000.00 was assessed today. :Residents medication closet was found to be open and medications were accessible to residents in care Department assessed penalty for $100.00 per day from 05/16/25 till date (total - $1300.00) since facility did not fulfill POC requirements which were due on 05/16/25. It should be noted that Department will assess future penalties for $100.00 per day till facility comply with POC requirements. : LPAs observed the facility to have a door stopper propping open the fire door in the hallway which is repeat violation from 05/01/25 visit, therefore repeat citation was issued. Immediate civil penalty of $1000.00 was assessed today. : Facility could not provide any paperwork related to staff, S1 when asked for department audit, which is a repeat violation of regulation 87412(f),therefore repeat citation was issued. Immediate civil penalty of $1000.00 was assessed today. As a result of today’s visit deficiency was cited as indicated on LIC809-D. Civil penalties shall be assessed if facility does not comply with POC requirements which were issued today. Exit interview conducted and a copy of the report, LIC809G and appeal rights was left at the facility.the state’s words, verbatim · CDSS document, May 28, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e) · Plan of correction due date: May 29, 2025

87355-(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by: Based on record review, Department found out that staff, S1 was not fingerprint cleared and was working at the facility which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 28, 2025

Plan of correction: Licensee will make sure that all staff must be fingerprint cleared prior to working in the facility. POC due by 05/29/25. Immediate civil penalty of $1000.00 was assessed today.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(h)(2) · Plan of correction due date: Jun 5, 2025

87465-(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above as medications closet was found to be open and medications were accessible to residents, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 28, 2025

Plan of correction: Administrator shall train staff regarding this regulation and send proof to Department. Department assessed penalty for $100.00 per day from 05/16/25 till date since facility did not fulfill POC requirements which were due by 05/16/25.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: May 29, 2025

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above as LPAs observed facility fire door to be propped open with a door stopper which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 28, 2025

Plan of correction: Staff immediately closed fire door and stated that the facility will keep it closed. Administrator shall send a letter of understanding of this regulation by POC date- 05/29/25. Facility shall plan how to stay in compliance with facility's fire clearance plan. Immediate civil penalty of $1000.00 was assessed today.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(f) · Plan of correction due date: Jun 5, 2025

87412-(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement is not met as evidenced by: Based on staff interviews, staff have no access to staff's ,S1, records for Department audit, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 28, 2025

Plan of correction: Administrator shall letter of understanding of this Regulation and shall train staff regarding this regulation and send proof to Department by POC date- 06/05/25. Facility will ensure to have staff records accessible per Department audit. Immediate civil penalty of $1000.00 was assessed today.

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Talwinder Bains and Lavinia Muscan arrived at the facility unannounced on May 28, 2025 to do a case management visit . LPAs met with Administrator, Irene Nepomuceno and explained the purpose of the visit. Incident for Resident, R1- LPAs arrived at the facility on a follow-up case management. However, upon arrival, Administrator Irene Nepomuceno told LPAs about an incident regarding funds that were missing from R1s bank account in the amount of $900. Administrator stated that a staff member (S1) wrote 2 checks to themselves, as reported by R1 and their responsible party on May 27, 2025. R1's family notified law enforcement, who were present at the time of department visit on May 28, 2025. Administrator stated that they will report this incident to the department via LIC624 as required by Reporting Requirements. Department conducted interviews with 1 resident, 2 witnesses, and 1 staff during today's visit. At this time, this incident is under review and department will do follow up if warranted. No citations were issued per Title 22 Regulations. Exit interview conducted and copy of the report left at facility.the state’s words, verbatim · CDSS document, May 28, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Talwinder Bains arrived on 05/01/25 to conduct the annual inspection. LPA met with staff Tonya Miles and explained the purpose of today's visit. LPA was notified by staff that administrator was not available today to assist with today's visit. LPA Cheyenne Ratajczak and Licensing Program Manager (LPM), Laura Munoz came after short while to assist with today's visit. Administrator Irene Nepomuceno arrived at 11:32 AM. Following issues were also observed during annual inspection; LPA observed the facility to have a door stopper propping open the fire door in the hallway. LPA found out from staff interview that resident, R1 was sent out to hospital due to right hip fracture on 03/24/25 but facility did not report this incident to Department per Reporting Requirements. Deficiencies cited as indicated on LIC809-D, civil penalties assessed. Exit interview and a copy of the report ,LIC809G and appeal rights left at the facility.the state’s words, verbatim · CDSS document, May 1, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: May 2, 2025

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above as LPAs observed facility fire door to be propped open with a door stopper which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 1, 2025

Plan of correction: Staff immediately closed fire door and stated that the facility will keep it closed. Administrator shall send a letter of understanding of this regulation by POC date- 05/02/25. Failure to provide POC by due date may result to civil penalty of $100 per day until received.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211 · Plan of correction due date: May 15, 2025

87211-Reporting Requirements- (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following... this requirement is not met as evidence by; Staff interview reflected that resident, R1 was sent out to hospital after fall incident with right hip fracture on 03/24/25 but facility did not report this incident to Department per requirement which poses a potential safety and health risks to residents in care.the state’s words, verbatim · CDSS document, May 1, 2025

Plan of correction: Administrator shall send a letter of understanding of this regulation by POC date- 05/15/25 and will make sure to send all reportable incidents/reports to Department as required.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Talwinder Bains arrived on 05/01/25 to conduct the annual inspection. LPA met with staff Tonya Miles and explained the purpose of today's visit. LPA was notified by staff that administrator was not available today to assist with today's visit. LPA Cheyenne Ratajczak and Licensing Program Manager (LPM), Laura Munoz came after short while to assist with today's visit. Administrator Irene Nepomuceno arrived at 11:32 AM. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, and common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. LPA checked the kitchen area for the ability to prepare and store food. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Following issues were observed during today's visit: Medications accessible to residents, Staff working without fingerprint clearance, Department has no access to staff and residents records, no administrator accessible /working during today's visit, accessible knives, chemicals and laundry supplies to residents, and citations were issued as listed on LIC809-D. LPA requested a copy of the LIC308, LIC 500, LIC610E and current liability insurance to be sent to the Department by 05/15/25. Deficiencies were observed and cited per Title 22, CCR Regulations as listed on LIC 809-D. Civil penalties shall be assessed if facility does not comply with POC requirements which were issued today. Exit interview conducted. Copy of this report ,LIC809G and appeal rights were provided.the state’s words, verbatim · CDSS document, May 1, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Talwinder Bains arrived on 05/01/24 to conduct the annual inspection. LPA met with administrator, Irene Nepomuceno and explained the purpose of today's visit. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed one (1) resident and one (1) staff files . Facility was clean and well organized. All required postings were observed. Deficiencies were observed during residents and staff's files review as listed on 809-D. LPA and Administrator toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, and common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. All exits were unobstructed. There is a side gate for emergency access. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Fire extinguisher was last serviced on 01/15/24 and was ready for emergency use. Hot water temperature was observed to be 120 degrees F, which is within the regulation range of 105-120 degree. Inside temperature was observed at 72 degree F. LPA requested a copy of the LIC 500, LIC610E and current liability insurance to be sent to the Department by 05/30/24. Deficiencies were observed and cited per Title 22, CCR Regulations as listed on 809-D. Exit interview conducted. Copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 1, 2024

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.