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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608815
Report Date: 06/27/2024
Date Signed: 06/27/2024 07:34:39 PM

Substantiated


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
06/21/2024 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20240621105259
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:
06/27/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Rima Abelian, Administrator TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not ensure the safety of food products provided to residents.
Staff did not assist resident with hygiene care.
Staff do not provide planned activities for residents.
INVESTIGATION FINDINGS:
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At 10:00am, Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced initial complaint visit at this facility to investigate the above allegations. LPA met with S1, who granted access to the facility. The Administrator arrived shortly after and LPA explained the reason for the visit.

During course of the investigation, interviews and record review were made. At 10:05am, LPA requested resident and staff roster. At 10:10am, LPA requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, Personal & Incidental (P&I) Log, relevant to the investigation. At approximately 10:15am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 10:20am – 12:30pm, LPA interviewed the Administrator, two (2) staff, and five (5) out of six (6) residents.

Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
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 6
Control Number 31-AS-20240621105259
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: 06/27/2024
NARRATIVE
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Allegation: Staff did not ensure the safety of food products provided to residents.

On 06/20/2024 a credible witness conducted a routine inspection at the facility and observed expired, up to two years, perishable and nonperishable food items in the pantry, refrigerator, and freezer. During today’s visit, LPA conducted an interview with the Administrator who confirmed that the expired food had been already thrown away and new groceries have been purchased and re-stocked. Based on today’s interview and the information gathered this allegation is Substantiated.

Allegation: Staff did not assist resident with hygiene care.

It was alleged that on 06/20/2024 a credible witness conducted a routine inspection at the facility and observed R1 had overgrown toe nails and indications of a fungal infection on a big toe. To investigate this allegation, LPA conducted an interview with the Administrator who confirmed that R1 hasn't been seen by a Podiatrist for some time. Administrator also informed LPA that R1's doctor had been notified and a Podiatry referral had been approved. However, R1's request for an appointment is still pending. Based on today’s interview and the information gathered this allegation is Substantiated.

Allegation: Staff do not provide planned activities for residents.

It was alleged that the facility does not provide planned activities for the residents. To investigate this allegation, LPA conducted an interview with the Administrator and was informed the facility does not have planned activities for the residents. There are some board games or television for residents to partake in, but nothing planned. Moreover, five (5) residents interviewed confirmed that they only come out from their rooms during the meal hours and once they are done, they go back to their room with no further activities. Based on today’s interview and the information gathered this allegation is Substantiated.

Deficiencies issued per Title 22.

Exit interview conducted appeal rights explained and copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 31-AS-20240621105259
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/04/2024
Section Cited
CCR
87555(b)(8)
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General Food Service Requirements: (b) The following food service requirements shall apply: (8) All food shall be of good quality...

This requirement is not met as evidenced by:
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Correction was cleared during todays visit.
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Based on the inspection conducted by a credible witness on 06/20/24, the licensee did not comply with the section cited above by having an expired food at the facility, which poses/posed a potential health and safety risk to persons in care.
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Type B
07/04/2024
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility...
(1) The licensee shall arrange, or assist in arranging, for medical and dental care...
This requirement is not met as evidenced by:
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Administrator will schedule an appointment for R1 to be seen by a Podiatrist and provide LPA with the appointment date.
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Based on the inspection conducted by a credible witness on 06/20/24, the licensee did not comply with the section cited by not making necessary arrangement for R1 to be seen by a Podiatrist, which poses a potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 31-AS-20240621105259
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/04/2024
Section Cited
CCR
87219
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Planned Activities: (a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities... (3)Leisure time activities cultivating personal interests...
This requirement is not met as evidenced by:
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Administrator will submit a copy of facility’s monthly activity schedule. Administrator will also submit a statement of understanding on how the facility, moving forward, will provide/engage residents in an activity.
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Based on interviews, licensee did not comply with the section cited above by not providing planned activities for the residents, which poses a potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
06/21/2024 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20240621105259

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:
06/27/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Rima Abelian, Administrator TIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff restrict residents to their rooms.
Staff are withholding residents’ personal funds.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At 10:00am, Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced initial complaint visit at this facility to investigate the above allegations. LPA met with S1, who granted access to the facility. The Administrator arrived shortly after and LPA explained the reason for the visit.

During course of the investigation, interviews and record review were made. At 10:05am, LPA requested resident and staff roster. At 10:10am, LPA requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, Personal & Incidental (P&I) Log, relevant to the investigation. At approximately 10:15am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 10:20am – 12:30pm, LPA interviewed the Administrator, two (2) staff, and five (5) out of six (6) residents

Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 31-AS-20240621105259
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: 06/27/2024
NARRATIVE
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Allegation: Staff restrict residents to their rooms.

It was alleged that residents are not allowed to come out to common areas, such as living room and back yard, and are kept in their room whole day. To investigate this allegation, LPA conducted an interview with the Administrator and two (2) staff, and all parties interviewed denied the allegation. In addition, LPA conducted interviews with six (6) residents and five (5) out of six (6) residents who were able to communicate also denied the above allegation and informed LPA that no such restrictions were made by the facility and all residents are allowed to come to the living room anytime. Based on today’s interview and the information gathered this allegation is deemed Unsubstantiated.

Allegation: Staff are withholding residents’ personal funds.

It was alleged that the residents' personal funds are not being provided to them and are being withheld by the staff. To investigate this allegation, LPA conducted an interview with the Administrator who denied the above allegation. LPA was informed that residents can access their funds by making a request. After the request, the funds get disbursed in the form of cash and a P&I log is being signed by the resident upon receipt. LPA was also provided with copy of the bond, signed and dated on October 28th, 2022 along with P&I log records. LPA reviewed the records and counted the funds. LPA observed P&I log, receipts and savings funds to be complete and accurate. Moreover, interviews with five (5) out of six (6) confirmed that they receive their P&I funds upon request and expressed no concerns regarding this allegation. Based on today’s interview, record review and the information gathered, the facility did not mismanage resident funds. Therefore, this allegation is deemed Unsubstantiated.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6