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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347003297
Report Date: 12/11/2024
Date Signed: 12/11/2024 03:36:42 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/15/2024 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20240515123429
FACILITY NAME:LA SERENA HOUSEFACILITY NUMBER:
347003297
ADMINISTRATOR:VILLAROSA, MARIBELFACILITY TYPE:
740
ADDRESS:8970 LA SERENA DRIVETELEPHONE:
(916) 966-0865
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 4DATE:
12/11/2024
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Aida Briones, LicenseeTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff handled resident in a rough manner.

Staff is not treating residents with dignity.

Staff broke resident’s wheelchair.

Staff sleep while on duty.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Licensee, Aida Briones, to deliver findings into the complaint allegations listed above.

During the investigation, the Department conducted interviews, toured the facility, and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

** Report continued on 9099-C **
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
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 3
Control Number 59-AS-20240515123429
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LA SERENA HOUSE
FACILITY NUMBER: 347003297
VISIT DATE: 12/11/2024
NARRATIVE
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A relevant party reported to the Department that staff member (S1) handled resident (R1) in a rough manner, was not treating R1 with dignity, and broke R1's wheelchair. Interview with relevant party indicated that they did not personally witness these allegations but was told about the allegations after speaking with R1. Relevant party also stated that S1 was witnessed to appear as if they had just woke up before answering the front door. Relevant party stated that they did not personally witness the incident in which S1 answered the front door. Interview with R1 confirmed the allegations addressed in the complaint regarding S1. However, R1 stated that S1 slept at night when the other residents were asleep.

Interviews conducted with residents (R2 and R3) indicated that the knew both R1 and S1 and stated that they never witnessed any of the allegations addressed in the complaint or experience any of the allegations addressed in the complaint. R3 stated that they thought S1 did a good job at the facility and did "above and beyond" in regards to providing care to the residents. Interviews conducted with staff members (S2 and S3) and Licensee indicated that they never witnessed any of the allegations addressed in the complaint. S2 stated that they knew both R1 and S1. S2 stated that S1 taught them a lot about the residents and S2 never witnessed anything offensive to make S2 question S1 as a caregiver. Interviews conducted with residents R2, R3, R4, and R5 indicated that they feel they are treated well by facility staff and their care needs are being met at the facility.

R1's Admission Agreement indicates that R1 was admitted to the facility on 3/16/2024. R1's hospice records indicate that R1 was admitted to hospice services on 3/16/2024. A review of R1's hospice records did not indicate any additional witnesses regarding allegations addressed in complaint. Interview with representative from R1's hospice agency indicated that they did not witness the allegations addressed in the complaint. Hospice records indicate education was provided to S1 regarding transfer assistance to R1. Hospice records indicate R1's sustained an unwitnessed fall on 4/23/2024, in which paramedics assisted R1 back into their wheelchair with no injuries reported.

** Report continued on 9099-C **
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20240515123429
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LA SERENA HOUSE
FACILITY NUMBER: 347003297
VISIT DATE: 12/11/2024
NARRATIVE
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Based on interviews conducted and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview was conducted with Licensee. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3