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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608600
Report Date: 08/10/2023
Date Signed: 08/10/2023 02:10:33 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/02/2023 and conducted by Evaluator Christopher Alemoh
COMPLAINT CONTROL NUMBER: 31-AS-20230802113335
FACILITY NAME:SERENE LIFE SENIOR CAREFACILITY NUMBER:
197608600
ADMINISTRATOR:SAMUEL C. TANFACILITY TYPE:
740
ADDRESS:11221 LULL STREETTELEPHONE:
(818) 308-6578
CITY:SUN VALLEYSTATE: CAZIP CODE:
91352
CAPACITY:6CENSUS: 6DATE:
08/10/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Rima AbelianTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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2
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9
Staff did not prevent resident from being injured by another resident.
INVESTIGATION FINDINGS:
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13
Licensing Program Analysts (LPAs) Christopher Alemoh and Michael Cava conducted a complaint visit to the facility to investigate the above allegation. It was reported that on or around 07/24/23, because of neglect by staff, Resident 1 (R1) was assaulted by Resident 2 (R2) causing injuries to R1. LPAs met with the administrator, Rima Abelian, and advised her of the complaint. Todays investigation consisted of interviews with staff and residents and record review. LPAs also conducted a physical plant inspection to insure the health and safety of the residents in care.

At approximately 9:30am to 12:00pm interviews made with the administrator, staff and residents. Interviews with the administrator and staff do not corroborate with the allegation. According to both administrator and staff, both residents are quiet and do not have a history of aggressive behavior. Interviews with R1 and R2 also do not corroborate with the allegation. Both residents stated they get along with their peers, and have not had any arguements with each other. Furthermore, interviews with four (4) out of four (4) residents
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Christopher Alemoh
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 31-AS-20230802113335
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SERENE LIFE SENIOR CARE
FACILITY NUMBER: 197608600
VISIT DATE: 08/10/2023
NARRATIVE
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reveal that each resident gets along with their peers, and have never witnessed their peers become aggressive towards one another. Between 12:00pm and 1:00pm, a record review made. LPAs review of resident files do not indicate aggressive or inappropriate behavior regarding R2.

Based on the information obtained, there was insufficient evidence to prove that staff did not prevent resident from being injured by another resident. Therefore, the allegation is deemed Unsubstantiated at this time.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Christopher Alemoh
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2