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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608815
Report Date: 01/17/2023
Date Signed: 01/17/2023 02:38:18 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/23/2021 and conducted by Evaluator Tihesha Smith
COMPLAINT CONTROL NUMBER: 31-AS-20210623144028
FACILITY NAME:SERENE NATURE ASSISTED LIVINGFACILITY NUMBER:
197608815
ADMINISTRATOR:SAMUEL C. TANFACILITY TYPE:
740
ADDRESS:10987 LUDDINGTON STREETTELEPHONE:
(818) 253-5989
CITY:SUN VALLEYSTATE: CAZIP CODE:
91352
CAPACITY:6CENSUS: 6DATE:
01/17/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Rima Abelian TIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Resident sustained injury as a result of general neglect
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Tihesha Smith and Abeye Duguma made a subsequent unannounced complaint visit to the facility and met with facility staff and explained the purpose of this visit. The administrator, Rima Abelian was contacted and arrived later.
During initial visit, on 10/27/2022, LPA Smith conducted tour of physical plant at 10:45 am, conducted interviews with administrators and requested documents relevant to the investigation between 11:30 am – 12:45 pm

Resident sustained injury as a result of general neglect
At 10:00 AM, LPAs conducted a physical plant tour, interviewed four (04) out of seven (07) residents, and two (02) staff from 10:45 AM – 12:00 PM and requested pertinent documents at 12:15 PM. LPAs unable to interview Resident #1 (R1) as R1 is deceased, Resident #6 (R6) is non-verbal, and Resident #7 is hospitalized.
During the physical plant tour, LPAs observed that all residents had proper bedding, residents were
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023
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-20210623144028
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SERENE NATURE ASSISTED LIVING
FACILITY NUMBER: 197608815
VISIT DATE: 01/17/2023
NARRATIVE
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(Cont from 9099)

observed to be clean and well groomed. During interviews residents revealed that they consistently have proper bedding. Resident #2 (R2) revealed that they shower only at night , once or twice a week, however, all other residents stated that they shower as often as they like and at minimum, every other day. Resident #4 (R4) is the only resident that needs assistance and stated that they receive assistance as needed and is satisfied with the hygiene schedule and care and services received at facility. R1’s roommate R3 stated that they did not witness R1’s fall, that they maintained good hygiene and never experienced any malodor. Interview with Resident #5 (R5) revealed they have bedding at all times, is able to shower as often as they like, and is satisfied with the care and services received at the facility.
Interview with Staff #1 (S1) revealed that R1 was on hospice care, ambulatory, not a fall risk but had two fall incidents while in care, and they did not witness R1 fall. S1 stated R1 and all other residents shower every other day or as needed. S1 stated the hospice service provided R1 with assistance with showering schedule and provided other hospice related services. Interview with Staff #2 (S2) revealed that all residents have proper bedding and adhere to a shower schedule without protest. Records show R1 is ambulatory and incontinent. Per interview with administrator hygiene care and incontinence care provided by hospice and staff assists as needed. Administrator also revealed staff consistently observe and check on residents and do not neglected residents in care.

Based on observations, interviews, and records reviewed there is insufficient pertinent information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards noted during the visit.

Exit interview conducted and a copy of the report was issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2