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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603601
Report Date: 12/05/2025
Date Signed: 03/20/2026 08:48:45 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
06/26/2025 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250626151821
FACILITY NAME:GRANT SERENITY OF DEL MAR INC.FACILITY NUMBER:
198603601
ADMINISTRATOR:ADJIAN, MARTINFACILITY TYPE:
740
ADDRESS:3049 E. DEL MAR BLVDTELEPHONE:
(818) 425-6797
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY:6CENSUS: 6DATE:
12/05/2025
UNANNOUNCEDTIME BEGAN:
08:13 AM
MET WITH:Gohar Armani TIME COMPLETED:
10:40 AM
ALLEGATION(S):
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Staff did not prevent resident in care from sustaining multiple pressure injuries while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 12/05/2025 regarding the above allegation. During today’s visit LPA Ramirez was greeted by Gohar Armani and explained the purpose of the visit.

SEE 9099-C for continued report.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026
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 28-AS-20250626151821
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GRANT SERENITY OF DEL MAR INC.
FACILITY NUMBER: 198603601
VISIT DATE: 12/05/2025
NARRATIVE
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The investigation consisted of the following: LPA Ramirez requested and obtained a copy of Resident/Client Roster, copies of Resident#6 (R6): Admission Agreement, Medical Assessment, Identification and Emergency Information, Appraisal/Needs and services plan, Medication Administration Record (MAR) for March – May 2025, Vital logs Jan-April 2025, Repositioning/Diaper Change Log for March, April and May 2025, R6's Hospital Medical Records, R6's Home Health Medical Records, R6's Medical Records copy of Staff Roster, Staff#1 - 5 interviews (S1 – S5) conducted by LPA Ramirez, Resident#2, 5 interviews (R2, R5) conducted by LPA Ramirez, Interview with resident#4’s (R4) family conducted by LPA Ramirez, Interviews conducted by Community Care Licensing-Investigations Branch, Investigations Branch-Investigation Report completed 10/7/2025, and physical plant tour.

The investigation revealed the following: regarding the allegation “Staff did not prevent resident in care from sustaining multiple pressure injuries while in care.” Interviews conducted by Community Care Licensing-Investigations Branch corroborated this allegation. Records reviewed by Community Care Licensing-Investigations Branch revealed that R6 was discharged from a local hospital on 03/19/2025 with a Stage I coccyx pressure injury and R6 was admitted to the facility on 03/19/2025. Records reviewed by Community Care Licensing-Investigations Branch revealed that in April of 2025, R6's Home Health and R6's physician noted several pressure injuries had developed on R6’s feet, ranging from Stage II to unstageable, and R6’s coccyx pressure injury had progressed to Stage II. On 04/29/2025, R6 was taken to a local hospital due to worsening pressure injuries. During the examination of R6, attending physician noted the pressure injuries were likely caused by the care at the facility. Interview conducted by Community Care Licensing-Investigations Branch with R6's Home Health nurse revealed that R6’s pressure injuries continued to worsen and develop new pressure injuries due to the staff’s inability to follow repeated education and instructions on pressure injury care and that with frequent repositioning, R6’s pressure injuries “could have been avoided.” R6's Home Health nurse revealed that on one occasion, staff were observed applying cream to R6’s coccyx injury but staff did not apply the dressing to keep the area dry, as instructed. Interviews conducted by Community Care Licensing-Investigations Branch with facility staff revealed that staff were not repositioning R6 often as needed. The information gathered during this investigation noted that R6’s pressure injuries worsened due to staff not following instructions pertaining to proper care and lack of timely repositioning. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated.

One (1) deficiency was issued. The licensee was informed that a civil penalty might be assessed based on the Health & Safety Code 1569.49(e) or (f), or 1548(e) or (f), or 1568.0822(e) or (f). Exit interview was conducted. A copy of this report, 9099-D, and appeals rights were provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20250626151821
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GRANT SERENITY OF DEL MAR INC.
FACILITY NUMBER: 198603601
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/08/2025
Section Cited
CCR
87468.2(a)(4)
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(a) residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by
staff that are sufficient in numbers, qualifications, and competency to meet
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Licensee will develop and submit a plan outlining the procedures and protocols for ensuring that staff adhere to specific care instructions for residents. Plan must be received by 12/08/25 via email to LPA Ramirez.
Kimberly.ramirez@dss.ca.gov
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 their needs. This requirement was not met as evidenced by: staff did not following instructions pertaining to pressure injury care which resulted in R6's worsening pressure injuries. This poses an immediate risk to the health, safety, or personal rights of 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: Fernando Fierros
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
06/26/2025 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250626151821

FACILITY NAME:GRANT SERENITY OF DEL MAR INC.FACILITY NUMBER:
198603601
ADMINISTRATOR:ADJIAN, MARTINFACILITY TYPE:
740
ADDRESS:3049 E. DEL MAR BLVDTELEPHONE:
(818) 425-6797
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY:6CENSUS: 6DATE:
12/05/2025
UNANNOUNCEDTIME BEGAN:
08:13 AM
MET WITH: Caregiver Gohar ArmaniTIME COMPLETED:
10:40 AM
ALLEGATION(S):
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Staff handled resident in a rough manner resulting in an injury.
Staff shared resident's medication between other residents in care.
Staff did not implement proper infection control practices.
Staff covered resident's face with a beanie.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 12/05/2025 regarding the above allegation. During today’s visit LPA Ramirez was greeted by Gohar Armani and explained the purpose of the visit.

The investigation consisted of the following: LPA Ramirez requested and obtained a copy of Resident/Client Roster, copies of Resident#6 (R6): Admission Agreement, Medical Assessment, Identification and Emergency Information, Appraisal/Needs and services plan, Medication Administration Record (MAR) for March – May 2025, Vital logs Jan-April 2025, Repositioning/Diaper Change Log for March, April and May 2025, copy of Staff Roster, Staff#1 - 5 interviews (S1 – S5) conducted by LPA Ramirez, Resident#2, 5 interviews (R2, R5) conducted by LPA Ramirez, Interview with resident#4’s (R4) family conducted by LPA Ramirez, and physical plant tour. SEE 9099-C for continued report.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20250626151821
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GRANT SERENITY OF DEL MAR INC.
FACILITY NUMBER: 198603601
VISIT DATE: 12/05/2025
NARRATIVE
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The investigation revealed the following: regarding the allegations “Staff handled resident in a rough manner resulting in an injury.” Interviews conducted by LPA Ramirez with five (5) staff did not corroborate this allegation. Staff interviews revealed R6 would become combative and aggressive with staff when staff tried to assist R6 with ADL’s (activities of daily living). Staff revealed R6 would get agitated and combative when staff attempted to put shoes on R6, as a result staff revealed they would allow R6 “space” and contacted R6’s family to inform them of R6’s refusal to wear shoes for walking and combativeness. Six (6) out of the six (6) staff interviewed denied handling R6 in a rough manner that resulted in an injury. LPA Ramirez reviewed R6’s facility file and did not observe facility incident reports that indicated R6 sustained an injury due to staff handling R6 in a rough manner. LPA Ramirez interviewed R4’s family and they revealed that they are in the facility most days for several hours and have never witnessed staff being aggressive or rough with residents. Two (2) out of the two (2) residents interviewed denied this allegation. Interview with R2 revealed that staff were “caring” with all the residents. Three (3) out of the five (5) residents in care were unable to be interviewed due to cognitive impairments. Due to cognitive impairments, R6 was unable to be interviewed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

“Staff shared resident’s medication between other residents in care.” Interviews conducted by LPA Ramirez with five (5) staff did not corroborate this allegation. Staff interviews revealed no medication is shared between residents because each resident has a different prescription and strength. Two (2) out of the two (2) residents interviewed denied this allegation. Interview with R4’s family revealed that R4 has always received their medication in a timely manner and medication was administered according to R4’s physician’s order. Three (3) out of the five (5) residents in care were unable to be interviewed due to cognitive impairments. Due to cognitive impairments, R6 was unable to be interviewed. During the record review, LPA Ramirez examined the medication administration record (MAR) for five (5) out of the five residents in care and did not observe any discrepancies. During facility tour, LPA Ramirez conducted an observation of staff administering medication to residents in care and noted no irregularities or concerns. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

SEE 9099-C for continued report

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20250626151821
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GRANT SERENITY OF DEL MAR INC.
FACILITY NUMBER: 198603601
VISIT DATE: 12/05/2025
NARRATIVE
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“Staff did not implement proper infection control practices.” Interviews conducted by LPA Ramirez with five (5) staff did not corroborate this allegation. Staff interviews revealed that staff clean and disinfect high trafficked areas at least every 2 hours and staff always wear gloves while providing first aid, toileting and when bathing residents. During record review of personnel records, LPA Ramirez observed annual staff training on infection control practices. LPA Ramirez examined the facility approved Infection Control Plan. During facility tour, LPA Ramirez conducted an observation of staff administering medication to residents in care and noted staff were wearing gloves and a face mask. LPA Ramirez observed the facility to be free from odors and did not observe potential hazards. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

“Staff covered resident’s face with a beanie.” Interviews conducted by LPA Ramirez with five (5) staff did not corroborate this allegation. Two (2) out of the two (2) residents interviewed denied this allegation. Interview with R4’s family revealed that they have only observed staff to be professional with their loved one and other residents in the facility. Three (3) out of the five (5) residents in care were unable to be interviewed due to cognitive impairments. Due to cognitive impairments, R6 was unable to be interviewed. During record review of personnel records, LPA Ramirez did not observe documentation of staff being reprimanded treatment of residents in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies were cited for these allegations. Exit interview was conducted. A copy of this report was provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6