Serenity Villa

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 dRead the full finding— CDSS inspection report, March 4, 2025 · control 21-AS-20241209155517

Licensing Program Analyst Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Licensee German Sinitsyn. The Department received an allegation of facility is not following resident’s special diet. Per Reporting party, staff report to Licensee that an unknown resident had a recent modification of diet texture (puree) due to potential choking incident, which was then disregarded by the licensee, who permitted staff to provide the resident with a food outside of their diet texture recommendation/order. In addition, there has been a lack of follow-through with diet texture recommendations and education to staff regarding safe and unsafe foods for resident (R1) and another resident (name unknown) where staff have expressed that they "use their best judgement", thereover putting the residents at risk of aspiration, choking, and/or death by not supervising residents during their mealtimes. Continued on LIC9099C... UnRead the full finding— CDSS inspection report, December 17, 2024 · control 21-AS-20241015114030

Licensing Program Analyst (LPA) Cuadra arrived unannounced at the facility and met with staff Erica Campos to deliver findings regarding the complaint allegation above. Licensee Aida Reznik was not able to come to the facility, but was available by phone and gave authorization for staff to sign the report. There was an allegation of facility did not seek timely medical attention. Per Reporting Party, resident’s (R1) sock with blood was observed by a witness, it was surprising that facility staff who assisted resident with daily activities did not discover the sore of considerable size and depth on their right foot sock. During this investigation, The Department investigator conducted interviews with staff and other witnesses, reviewed records associated to the involved R1. Based on interviews conducted and records obtained, the investigation revealed that on 7/29/23, the pressure ulcer on R1’s right heel was noticed by a witness. According to home health records, R1 received skilled nuRead the full finding— CDSS inspection report, December 12, 2023 · control 21-AS-20230905113442

Licensing Program Analyst (LPA) Cuadra arrived unannounced at the facility and met with staff Erica Campos to deliver findings regarding the complaint allegation above. Licensee Aida Reznik was not able to come to the facility, but was available by phone and gave authorization for staff to sign the report. Complaint received on 9/22/2023 alleged that Facility is not ensuring safety of residents in care. Per Reporting Party, the front door to the residence was observed ajar without any alarm sound. The front door leads down five steep steps to the sidewalk and is adjacent to a busy street. Although most of the residents are non-ambulatory, a few can self-propel throughout the building with walkers and wheelchairs, and this poses a significant threat to safety. Upon inquiry to facility staff, apparently, they were not aware of the significant safety issue nearby. The licensee informed LPA that the front entrance door is challenging at times, it expands during the rainy season and shrinksRead the full finding— CDSS inspection report, October 24, 2023 · control 21-AS-20230922100208

Licensing Program Analyst (LPA) Cuadra arrived unannounced to the facility met with Maritza Pray, Administrator to deliver findings regarding the complaint allegation above. Regarding allegation of Staff mismanaged resident medication. Reporting Party reported that the R1 was prescribed on 1/30/23 a long acting pill twice a day for pain and would continue to have morphine as needed. However, on 2/1/23 R1 was found in excruciating pain, moaning and could not hold still. When they inquired to staff, they were told that the facility had not received medication prescribed. Also, staff told them that they could not give the resident medication if they don’t ask for it. Based on records review R1 was prescribed with Morphine 100mg/5ml oral solution on 1/28/23 as needed every 4 hours/PRN, based on Centrally Stored Medication and Destruction (CSMD) log, the medication was received at the facility on 1/29/23. On 1/31/23 R1 was prescribed 1 tablet of Morphine 15mg every 4 hours as needed for paiRead the full finding— CDSS inspection report, March 28, 2023 · control 21-AS-20230209141814