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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200887
Report Date: 12/27/2024
Date Signed: 12/27/2024 01:23:28 PM

Document Has Been Signed on 12/27/2024 01:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:SERENITY HOME IIFACILITY NUMBER:
019200887
ADMINISTRATOR/
DIRECTOR:		SARMIENTO, EDITHFACILITY TYPE:
735
ADDRESS:40429 FOSTER STREETTELEPHONE:
(510) 731-7822
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 6CENSUS: 4DATE:
12/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Elma Cabrito, Care Staff TIME VISIT/
INSPECTION COMPLETED:
01:35 PM
NARRATIVE
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On 12/27/2024 at 10:05 AM, Licensing Program Analyst (LPA) P. Manalo and arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Care Staff, Elma Cabrito, who phoned the Administrator and explained the purpose of the visit. Administrator, Edith Sarmiento, gave authorization on the phone for Elma to sign the report. Administrator certificate is current and expires on 06/12/2025. The facility’s fire clearance was approved for all six (6) ambulatory.

LPA toured the facility inside and out including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms in which 1 room is occupied by staff and 4 bedrooms are occupied by the clients. There are no bodies of water. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 123.7 degree Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygiene's was available for clients. There is a minimum of one week supply of nonperishable and 2-day perishables food supply. Centrally stored medication and sharps were locked and inaccessible to clients.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 10/10/2024. Emergency Disaster Plan was last posted on 04/02/2024. Fire drill was last conducted on 12/11/2024.

At 10:48 AM, 4 of clients records were reviewed. At 11:18 AM, 4 staff records were reviewed and 4 of 4 have current first aid training and 4 of 4 associated to the facility. At 11:41 AM, LPAs reviewed client's P&I money with log. At 11:51 AM, LPAs reviewed all clients' medications. All records were observed to be complete.

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SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 12/27/2024 01:23 PM - It Cannot Be Edited


Created By: Patricia Manalo On 12/27/2024 at 12:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SERENITY HOME II
FACILITY NUMBER: 019200887

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having the hot water temperature measured at 123.7 which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/28/2024
Plan of Correction
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 Administrator will also adjust water temperature to 105 - 120 degrees Fahrenheit and submit photo to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2024


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Document Has Been Signed on 12/27/2024 01:23 PM - It Cannot Be Edited


Created By: Patricia Manalo On 12/27/2024 at 12:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SERENITY HOME II
FACILITY NUMBER: 019200887

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in having trash bins in front of the side gate blocking the passageway which poses a potential health and safety risk to persons in care.
POC Due Date: 12/30/2024
Plan of Correction
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Staff removed the trash bin from the passageway during the visit. Deficiency cleared.
Type B
Section Cited
CCR
80075(g)(1)(A)
(A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not having a first aid manual in the first aid kit which poses a potential health and safety risk to persons in care.
POC Due Date: 12/30/2024
Plan of Correction
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Staff had bought a first aid manual during the visit. Deficiency cleared.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2024


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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SERENITY HOME II
FACILITY NUMBER: 019200887
VISIT DATE: 12/27/2024
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Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 01/06/2025:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610D Emergency Disaster Plan
Liability Insurance
Auto Insurance

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 10:20 AM, LPA observed the hot water temperature measured at 123.7 degrees F.

At 10:29 AM, LPA observed trash bins in front of the side gate blocking the passageway. Deficiency cleared during the visit.

At 12:00 PM, LPA observed that there was no first aid manual in the first aid kit. Deficiency cleared during the visit.


The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with Staff. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2024
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