Vista Sereno RCFE

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Domingo rang the door bell of the facility. The facility did not look occupied. LPA left a message for Dominique Mase.the state’s words, verbatim · CDSS document, Oct 17, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst LPA Amy Domingo attempted to conduct a 1 year annual inspection. LPA Domingo rang the door bell with no answer. LPA Domingo called Dominique Masa the Administrator and he stated that the facility and all the residents were moved to another location. LPA stated no paper work was sent to the Regional Office. He apologized and stated that his primary concern was safely moving the residents. He stated that he has 30 days to request or file for the facility to be closed. LPA stated that the information will be sent to him on closure of a facility.the state’s words, verbatim · CDSS document, Oct 17, 2025

Allegation investigated: Licensee submitted an application and other attachments that were not true or correct Licensee did not confirm adequate food for residents in care.

Licensing Program Analyst (LPA), Amy Rodgers, conducted an unannounced visit to conclude a complaint investigation at the facility. LPA was greeted by Care Giver Felimon Raturat , identified herself, was granted entry, and explained the purpose of the visit. The Department's investigation included a facility file and outside source records reviews, interviews conducted with the Licensee and an Outside Source, and a brief tour of the facility. It was alleged the Licensee submitted false information on the facility license application regarding the percentage of ownership not being equal (50%, each) between two applicants. Based on a file review the facility's Administration Organization documents (LIC 309), was processed at 70% for Applicant #1(AP1) and 30% For Applicant #2(AP2). The operating Agreement for Vista Serena RCFE LLC confirms the percentages and signatures for both AP1 and AP2 are present on the document. Unsubstantiated (continued from LIC 9099) It was also alleged the Licensee did not ensure residents in care received adequate food. An interview conducted with Licensee and facility tour confirmed the facility had four (4) clients. A department facility inspection was conducted October 9, 2024 and May 12, 2025 of the kitchen as well as food storage areas There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored Cooking/dining equipment and utensils were present. Interviews with Resident #1 (R1) confirmed thee are no issues in the home with food shortages. Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegation is not valid. An exit interview was conducted with Care Giver Felimon Raturat. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided emailed to the address provided by Care Giver Raturat and his signature on this report confirms receipt of the Licensee Rights.the state’s words, verbatim · CDSS document, May 12, 2025 · control 08-AS-20250506112345

Allegation investigated: Licensee had an incomplete file for administrator Licensee staff are not adequately trained

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to investigate a complaint and deliver investigative findings. LPA introduced herself, was granted entry into the facility, and met with Care giver Raturat Felimon to whom she disclosed the reason for the visit. Later Licensee/Administrator Domininique Mase joined the visit. It was reported to Community Care Licensing (CCL) on 10/2/2024 that Licensee had and incomplete file for the administrator and staff are not adequately trained. The Department’s investigation consisted of staff and client interviews, record reviews and outside source interviews. (Continued on 1099-C) Unsubstantiated (Continued from 1099) According to a review of records, all Licensee staff are adequately trained, and documentation is on file at Licensee facility. The regulations do state, HSC 1569.69(If Facility Capacity is 15 or Fewer: Ten (10) total hours of training on medication assistance, of which Six (6) hours must be hands-on training and four (4) hours will be other instruction.) and CCR 87411(c)(1) HSC 1569.618(b)(3), HSC 1569.618(c)(3)(First Aid Training Card/Certificate and Cardiopulmonary Resuscitation (CPR) ) as well as other Title 22 regulation required training be in completed before staff can work independently with clients. According to interview with the administrator, staff do have knowledge of training that was provided before staff started working independently with clients. According to a review of records, the Administered file was present and did include all required documents. The regulations do state, staff should meet personnel requirements specified under code CCR 87411(c)(1) and HSC 1569.618(b)(3)( First Aid Training Card/Certificate “….from persons qualified by such agencies as the American Red Cross.) as well as CCR 87406 (Administrator Certification Requirements) Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegation is not valid. An exit interview was conducted with Licensee Domininique Mase A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Administrator and his signature on this report confirms receipt of the Licensee Rights.the state’s words, verbatim · CDSS document, Oct 9, 2024 · control 08-AS-20241002143614

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, care giver Felimon Raturat to whom she discussed the purpose of the visit. Later Licensee/Administrator Dominique Mase joined the visit. According to the facility’s license, the facility has a maximum capacity of four (4) residents all of which may be non-ambulatory. During today’s inspection, there were a total of four (4) clients in care, all of which were non-ambulatory. This facility does not feature a secured perimeter or delayed egress doors. LPA, accompanied by licensee’s staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was compliant. There were two Refrigerator/Freezer units both of which had appropriate temperatures. There were two bathrooms accessible to clients both of which the hot water tap temperature was 116 degrees Fahrenheit (Continued on 809-C) (Continued from 809) There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required. Confidential records were stored in locked areas. Upon LPA's arrival, she observed that keys were hanging from the medication storage cabinet locks and part of the cabinet did not have locks and one lock was damaged. There were medications in the cabinet, so a deficiency was issued. No pools or bodies of water were observed on the premises. Per the licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher was serviced within the last 12 months. First aid kit were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed multiple staff and one client and reviewed multiple staff and client records/files. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Licensee also presented proof of current/active business liability insurance and surety bond A deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Licensee/Administrator Dominique Mase, to whom a copy of this report, the LIC 809-D, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Oct 9, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced Case Management visit to deliver an amended report for a visit conducted on 11/08/2023. LPA identified herself and was granted entry by Jolin Ly, caregiver. LPA met with Dominique John Mase, Licensee, and discussed the purpose of the visit. During today’s visit, LPA obtained Licensee’s signature on the amended report LIC 809 dated (01/24/2024) and deficiencies were issued on the attached LIC809-D. Please note that Advisory Notes – Technical Assistance (LIC 9102TA) were issued in error. An exit interview was conducted with Licensee Dominique Jonh Mase, to whom a copy of this report, the amended report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. The signature below confirms the receipt of these documents.the state’s words, verbatim · CDSS document, Jan 24, 2024

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.695(e) · Plan of correction due date: Feb 7, 2024

H&S 1569.695 Emergency Plans (e) A facility shall have all of the following information readily available to facility staff during an emergency: (1) A resident roster with the date of birth for each resident… this requirement was not met as evidenced by: Based on records review, the facility did not have a Resident Roster on file for 3 of 3 residents [R1, R2, & R3]. This posed a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 24, 2024

Plan of correction: The facility did fill out a resident roster form after the initial visit on 11/08/23. LPA obtained a copy of the resident roster dated 11/08/23. This POC is deemed cleared.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.695(c) · Plan of correction due date: Feb 7, 2024

H&S Code Section 1569.695 Emergency Plans (c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill… this requirement was not met as evidenced by: Based on records review, the facility did not have quarterly fire drills on file for the facility which posed a potential safety risk to 3 [R1, R2, and R3] of 3 persons in care.the state’s words, verbatim · CDSS document, Jan 24, 2024

Plan of correction: The fire drill form for the facility was filled out after the initial visit on 11/08/23 with one former fire drill they did not have on file for 10/2023 and a second fire drill conducted on 11/2023. LPA obtained a copy of the fire drill. This POC is deemed cleared.

Type of visit: Case Management - Incident

Licensing Program Analysts (LPA) Dang Nguyen and Juliana Barfield conducted an unannounced Case Management - Incident visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Caregiver Jolin Ly. LPAs also met and spoke with Administrator Dominique Mase, who arrived later during the visit. Today's visit was in response to licensee’s self-reported death of Resident #1 (R1), received at the CCLD San Diego Regional Office on 01/09/2024. [See LIC 811 Confidential Names List for a description of C1]. Per the report, R1 passed away on 01/05/2024. During today’s visit, LPAs performed a brief facility tour and welfare check on remaining clients, finding no safety concerns. LPA also collected copies of and reviewed pertinent records and interviewed relevant staff. No deficiencies were cited during today’s visit. However, one (1) Technical Violation was issued regarding Maintenance and Operation (see the LIC9102-TV). An exit interview was conducted with Ly. A copy of this report, the LIC9102-TV, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to the Licensee during the visit.the state’s words, verbatim · CDSS document, Jan 10, 2024