El Sereno Home

Type of visit: Required - 1 Year

On 4/27/26, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Staff Roberto Suarez. LPA explained the purpose of the visit. LPA toured the facility inside and outside including all of resident rooms and kitchen area. Facility is a single story home with six resident bedrooms. LPA observed residents resting in the living room and bedrooms. While touring the facility it was observed that the room temperature was at 69 deg F. Hot water temperature is at 109 degF. The facility is observed to be clean, odorless, and well maintained. All passageways are unobstructed. Residents bedrooms were observed to be well organized and fully furnished with adequate lighting. Sharps and toxic materials were observed to be locked. Food supply was observed with an adequate two day perishable and seven day non-perishable food supply. Carbon monoxide/ smoke detectors, and fire extinguisher were present throughout the facility. Facility has an updated log for emergency drill which is done every quarter. Six resident records and five staff records were reviewed. Staff have criminal record and fingerprint clearances on file. Staff have current First Aid/CPR certifications on file and updated trainings. Resident records were reviewed and were observed to be complete. All medication logs are complete and updated. No deficiencies are cited at this time. Report is reviewed and a copy is providedthe state’s words, verbatim · CDSS document, Apr 27, 2026

Type of visit: Required - 1 Year

On May 07, 2025, at 12:30 PM, the Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Required 1-Year Annual inspection. The LPA met with the Assistant Administrator (ADM), Ofelia Guanzon, and disclosed the purpose of the inspection. ADM informed the LPA that the facility had (6) residents in care and (2) staff members present at the time. The Licensee, Theresa Carr joined shortly after. At 12:48 PM, the LPA initiated a walk-through of the facility, accompanied by the ADM. LPA inspected the kitchen and found it clean, with no food preparation and cooking in progress at the time. The appliances were checked and observed to be in working order. The LPA inspected a locked cabinet drawer containing knives and sharp objects, and a locked cabinet under the sink with detergents and cleaning supplies. The refrigerator and pantry cabinets were inspected, and sufficient supplies of fresh perishable food for (2) days and nonperishable staples for (7) days were observed. No expired food or stored medications were noted. LPA inspected the living room and observed it clean, with all furniture in good repair. There was a sofa, recliners, side tables, a wall mounted television, and a piano in the living room. One (1) resident were observed sitting on a recliner. LPA inspected the dining area adjacent to the living room and found it clean. The dining table and chairs were observed to accommodate the residents, and all the furniture was in good repair. LPA inspected the family room and observed sofa, chairs, and a table in good repair. One (1) resident were observed sitting on a chair. Continued on LIC809-C LPA inspected the fire extinguisher mounted on the wall next to the the kitchen and found it fully charged, with the last service tag dated 04/30/2025. The ADM tested the smoke and carbon monoxide detector located in the hallway in the LPA's presence, and it was found to be functional. Additional smoke and carbon monoxide detectors were observed in all bedrooms and common areas of the facility during the visit. There were (6) bedrooms and (2½) bathrooms designated for residents' use. All (6) resident rooms were single occupancy. LPA inspected all (6) resident rooms and found them clean, well-lit, and equipped with the required furniture. Storage closets with incontinence supplies were observed in every room. At 1:05 PM, LPA observed a resident in bedroom #4 had a full bed rail and the resident was not receiving hospice care. LPA inspected (2½) bathrooms and found them clean, sanitary, and in good working condition. The bathrooms contained soap, grab bars, paper towels, a trash can, a shower chair, and non-slip flooring. At 1:16 PM, The hot water temperature at the sink faucet measured 117.3°F in bathroom #1 and 128.8°F in bathroom #2. LPA toured the backyard and side yard areas, found ramps and passageways in good condition, clear of obstructions, with no blocking or tripping hazards. The back yard areas have a set of a patio table, chairs, and shaded areas for resident use. No bodies of water were noted. A washer, a dryer and a detached office room were observed in the backyard. Three (3) additional refrigerators with freezer were observed and inspected in the backyard. LPA reviewed six (6) staff personnel records and five (5) resident records. The LPA observed that 5 of 5 residents had an Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, and CSDMR. LPA observed that 6 of 6 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening. At 2:04 PM, LPA observed 1 of 6 staff member was not associated with the facility. LPA observed a locked centrally stored medication cabinet under the kitchen breakfast bar. Medications were organized in separate bins for each resident. Centrally Stored Medication Records were reviewed and found to be complete. LPA inspected the first aid kit and found it fully stocked. Emergency Drill Logs were reviewed, and it was observed that Emergency Disaster Drills were conducted quarterly, with the most recent drill completed on 03/15/2025. Continued on LIC809-C The following updated forms are requested to be submitted to CCLD by 05/14/2025: LIC 500: Personnel Report LIC 308: Designation of Facility Responsibility Certificate of Liability Insurance Administrator Certificate(s) No deficiencies were cited during today's visit. An exit interview was conducted with the Assistant Administrator. A copy of this report was provided to the Assistant Administrator, Ofelia Guanzon, whose signature on this form confirms receipt of the report.the state’s words, verbatim · CDSS document, May 7, 2025

The state marks this report as 7 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Facility did not refund of former resident’s paid rent for December 2024

On March 11, 2025, at 12:15 PM, Licensing Program Analyst (LPA) Kiran Jain arrived at the facility to conduct a Complaint Investigation visit. Upon arrival, the LPA was greeted by the Assistant Administrator (AAD) Ofelia Guanzon. The LPA disclosed the purpose of the inspection. The AAD informed the LPA that there were six (6) residents in care. Regarding the allegation “Facility did not refund the former resident’s paid rent for December 2024”, the Reporting Party (RP) stated “resident (R1) passed away on 12/2/2024. RP stated they moved out all R1's belongings from the facility on 12/3/2024. RP stated based on R1's admission agreement/termination agreement, the facility shall return 27 days of R1's December 2024 monthly rent. RP stated R1's December 2024 monthly rent is $7665.00. RP stated she talked to Administrator Theresa Carr (ADM) several times, but ADM only agreed to refund 16 days of R1's December 2024 monthly rent. RP stated they haven’t received any refund from the facility yet.” Continued on LIC9099-C Unfounded On March 5, 2025, LPA interviewed Assistant Administrator (AAD) Ofelia Guanzon. AAD confirmed that R1 passed away on December 2, 2024, and that R1’s family member (FM1) picked up R1’s belongings on December 3, 2024. AAD also stated that R1’s hospice bed was removed from the facility on the same day. According to AAD, the facility issued a refund check on February 24, 2025, for the amount of $6,909.00, and FM1 picked up the check on March 1, 2025. On March 5, 2025, LPA attempted to contact FM1 by calling both their cell phone and home phone numbers, leaving voicemails requesting a callback. Follow-up calls were made to FM1’s home phone on March 6, 2025, March 7, 2025, and March 10, 2025, with additional voicemails left requesting a response. On March 10, 2025, LPA reviewed R1’s admission agreement, which indicated the termination of agreement upon the death of the resident and when all personal belongings are taken out by the family from the room. LPA reviewed R1’s death report, which confirmed that R1 was on hospice care and passed away on December 2, 2024. LPA also reviewed R1’s hospice discharge summary, which indicated that the last hospice visit occurred on December 2, 2024. Additionally, LPA examined documents received from the facility, which confirmed that a refund check for $6,909.00 was issued on February 24, 2025, and that FM1 picked up the check on March 1, 2025. Based on the interviews conducted and records reviewed, the department has determined that the allegation is false, could not have happened, and/or is without a reasonable basis. Therefore, the allegation is UNFOUNDED. No deficiencies were cited under the California Code of Regulations, Title 22. An exit interview was conducted with the Assistant Administrator. A copy of this report was discussed and left with the Assistant Administrator, Ofelia Guanzon, whose signature on this form confirms receipt of this report.the state’s words, verbatim · CDSS document, Mar 11, 2025 · control 26-AS-20250129132020

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Luisa Roman. During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo toured the facility kitchen area and observed the kitchen to have locked drawers for medications and sharps. LPA Marrufo toured three out of three resident bathrooms and observed the water temperatures to be 115 F, 114 F, and 113 F. Each bathroom had available soap and paper towels as well as functioning lights. LPA Marrufo toured six out of six resident bedrooms. Each bedroom had working lights, available bedding and clothing storage areas. LPA Marrufo tested the smoke detectors in each bedroom and hallway as well as two out of two carbon monoxide detectors. All detectors functioned properly when tested. LPA Marrufo reviewed the Centrally Stored Medication Logs, resident records, and staff records during visit. The Emergency Disaster Drill Log states the last drill was conducted on 04/28/2024. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Luisa Roman and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 21, 2024