198603601-4-17-2025-28-AS-RORN-DG2NR2-20250424104046

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603601
Report Date: 04/17/2025
Date Signed: 04/17/2025 01:57:01 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/24/2025 and conducted by Evaluator Mary G Flores

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250324121724

FACILITY NAME:	GRANT SERENITY OF DEL MAR INC.		FACILITY NUMBER:	198603601
ADMINISTRATOR:	ADJIAN, MARTIN		FACILITY TYPE:	740
ADDRESS:	3049 E. DEL MAR BLVD		TELEPHONE:	(818) 425-6797
CITY:	PASADENA	STATE: CA	ZIP CODE:	91107
CAPACITY:	6	CENSUS: 5	DATE:	04/17/2025
		UNANNOUNCED	TIME BEGAN:	11:19 AM
MET WITH:	Gohar Armani - Caregiver		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Facility staff did not assist resident with dental hygiene
Facility staff did not meet resident's incontinence care needs
Illegal Eviction

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegations. LPA met with Gohar Armani and explained the reason for the visit.

The investigation consisted of the following: On 4/1/25 conducted an initial complaint investigation visit and requested copies of staff/resident roster. LPA interviewed 4 residents, 2 responsible parties, and 3 staff and requested the following documents: medical assessment, identification and emergency information sheet, admission agreement, pre-appraisal, needs and care plan for resident #1(R1). On 4/3/25 LPA Flores received the requested documents. On 4/17/25 LPA Flores delivered findings for the above allegations.

The investigation revealed the following: Regarding allegation: Facility staff did not assist resident with dental hygiene. It is alleged resident was not assisted with brushing their teeth which developed into dental issues. (CONTINUED ON LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/17/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20250324121724

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GRANT SERENITY OF DEL MAR INC.	FACILITY NUMBER: 198603601
	VISIT DATE: 04/17/2025

NARRATIVE

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Interviews conducted with residents revealed 1 out of 4 residents stated facility staff does not assist with brushing their teeth, and 3 out 4 residents were unable to answer due to cognitive skills. Responsible parties’ interviews stated that have observed residents being assisted with dental hygiene during their visits. Interviews with staff revealed residents are assisted with dental hygiene twice a day in the morning and evening. Documents reviewed revealed per needs and care plan dated: 6/6/24 and physician’s report dated: 6/28/24, R1 needed assistance with most activities of daily living (ADLs) except for feeding. Needs and care plan does not specify the number of times per day of assistance with dental hygiene needs. Although, R1 may have developed dental issues, per interviews conducted and documents reviewed there is not sufficient evidence to determine the dental issues were cause due to lack of assistance of dental hygiene to R1. Therefore, the allegation is unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation: Facility staff did not meet resident’s incontinence care needs. It is alleged resident had many urinary track infections (UTI) due to staff not changing resident soil adult underwear. Interviews conducted with residents revealed, 1 out of 4 residents interview stated staff assist with incontinence care in a timely manner, 3 out of 4 residents were unable to answer due to cognitive skills. Responsible parties’ interview stated they do not have concerns on incontinence care provided to the residents in care. Interviews conducted with staff revealed, staff check on the residents at least every two hours and change the residents as needed. Per documents reviewed; Physician’s report dated: 6/28/24 notes R1 needs assistance with ADLs. Per needs and care plan dated 6/6/24 R1 will be assisted with change adult undergarment daily as needed. Nurse’s notes on 7/2/24 and 7/19/24 do not note concerns on incontinence care, or appearance of R1. One nurse note/communication was noted on 9/12/24 regarding concerns for a UTI. Although R1 may have had developed a UTI there is not sufficient evidence to determined that the UTI were cause due to lack of incontinence care provided to R1. Therefore, the allegation is unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.
(CONTINUED ON LIC 9099C)

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/17/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20250324121724

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GRANT SERENITY OF DEL MAR INC.	FACILITY NUMBER: 198603601
	VISIT DATE: 04/17/2025

NARRATIVE

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Regarding allegation: Illegal eviction. It is alleged resident was asked to leave the facility due to a higher level of care. Interviews conducted with residents revealed, 1 out of 4 residents stated to be aware of residents’ rights and means to an eviction, 3 out of 4 residents were unable to answer due to cognitive skills. Interviews conducted with responsible parties stated to be aware eviction and higher level of care process. Interviews with administrator and staff revealed R1’s responsible was not provided an eviction notice. Per documents reviewed, R1 was admitted to the facility on 7/2/24. Communication between facility and responsible party show that on 1/27/25 licensee communicated with responsible party via email about R1’s relocation for higher level of care for treatment and that the facility could hold R1’s bed if responsible party desires. R1’s responsible party responded and took the communication as a 30 day notice.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted with Gohar Armani and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/17/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

LIC9099 (FAS) - (06/04)

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