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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005803
Report Date: 09/21/2022
Date Signed: 09/21/2022 11:53:29 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/22/2022 and conducted by Evaluator Albert Marin
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220422100704
FACILITY NAME:A TOUCH OF SERENITY RESIDENTIAL CAREFACILITY NUMBER:
306005803
ADMINISTRATOR:REYES, NAYEHYFACILITY TYPE:
740
ADDRESS:24562 ARTEMIA AVETELEPHONE:
(949) 633-5336
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
09/21/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Juan Reyes TIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Resident sustained severe fracture while in care.
Staff did not seek medical attention in a timely manner.
Staff did not notify resident's authorized representative of incident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to this facility to deliver the final report for the investigation completed for the complaint received last April 22, 2022 against this facility. LPA met with Administrator (AD) Juan Reyes and discussed the findings.

Based on the information gathered during the investigation and review of documents obtained for the allegation that resident sustained severe fracture while in care, the following are the findings. Resident 1 (R1) was admitted in the facility in January 2022. R1 was place under hospice care with diagnosis of senile degeneration of the brain, and comorbidities which included Coronary Artery Disease (CAD), hypertension, and congestive heart failure. Per April 2022 Physician’s Report, R1 was evaluated to be confused, disoriented, with wandering behavior, not able to follow instructions and not able to communicate needs and needed maximum assistance with toileting needs. R1 had no reported fall incident until the early morning of April 20, 2022. Staff rushed to Resident’s room and observed R1 was on the floor. R1 was helped and denied having apparent injury. R1 was not in pain and responded well to questions. Fall was witnessed by Resident 2 (R2). (Continuation in Page 1)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
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 3
Control Number 22-AS-20220422100704
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: A TOUCH OF SERENITY RESIDENTIAL CARE
FACILITY NUMBER: 306005803
VISIT DATE: 09/21/2022
NARRATIVE
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(Continuation from Page 1) Fall incident was reported to hospice agency. R1 was evaluated by hospice nurse. X ray was requested and revealed “slightly displaced impacted subcapital fracture is noted Degenerative Joint Disease (DJD) is present and osteoporosis suggested. Right hip fracture”. R1 remained in the facility and managed with maximum assistance and medication. The Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation that resident sustained severe fracture while in care is deemed UNSUBSTANTIATED.

On allegation that staff did not seek medical attention in a timely manner, the following are the findings. The first fall incident for R1 occurred around 2:00 AM of April 20, 2022. R2 observed R1 got out of bed and began walking unsteadily before the fall. Staff rushed towards the room and observed R1 on the floor. Staff checked R1 and did not observe apparent injuries. R1 stated no pain and responded to questions well. Staff was assisting R1 to get to showers when R1 reported pain. Staff called hospice agency for evaluation. Around 9:00 AM, when hospice nurse arrived in the facility and evaluated R1. After the initial medical assessment was made, R1 remained in the facility and managed with pain medications. Thus, the allegation that staff did not seek medical attention in a timely manner is UNSUBSTANTIATED.

On allegation that staff did not notify authorized representative of the incident, the following are the findings. Per interviews, Responsible Party (RP) for R1 confirmed that RP received a report from Administrator (AD) Juan Reyes regarding the fall incident. Staff attempted to contact another authorized representative using the contact information available. Thus, the allegation that staff did not notify authorized representative of the incident is deemed UNSUBSTANTIATED.

LPA Marin conducted an exit interview with AD Juan Reyes. Copies of this report were left in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/22/2022 and conducted by Evaluator Albert Marin
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220422100704

FACILITY NAME:A TOUCH OF SERENITY RESIDENTIAL CAREFACILITY NUMBER:
306005803
ADMINISTRATOR:REYES, NAYEHYFACILITY TYPE:
740
ADDRESS:24562 ARTEMIA AVETELEPHONE:
(949) 633-5336
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
09/21/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Juan Reyes TIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
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9
Staff did not make sure residents call button was on.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to this facility to deliver the final report for the investigation completed for the complaint received last April 22, 2022 against this facility. LPA met with Administrator (AD) Juan Reyes and discussed the findings.

On allegation that staff did not make sure resident’s call button was on, the following are the findings. Based on observation and interviews completed during the April 25, 2022 visit in the facility, facility was not using any call button or system in the facility. Facility was providing two care staff members during day shift, and a night staff to supervise and assist six residents in care.

The Department has investigated the complaint alleging that staff did not make sure resident’s call button was on. all We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

LPA Marin conducted an exit interview with AD Juan Reyes. Copy of this report was left in the facility.


Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3