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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200967
Report Date: 05/12/2023
Date Signed: 05/12/2023 05:37:13 PM

Document Has Been Signed on 05/12/2023 05:37 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:SERENE CARE JACQUELINEFACILITY NUMBER:
079200967
ADMINISTRATOR:RANCES, RONAN BFACILITY TYPE:
740
ADDRESS:2297 JACQUELINE DRIVETELEPHONE:
(925) 267-9084
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 3DATE:
05/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Josephine Ambagan, Direct Support ProfessionalTIME COMPLETED:
05:50 PM
NARRATIVE
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On 5/12/2023 at 3:00PM, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual 1-year required inspection. LPA met with Josephine Ambagan, Direct Support Professional, and explained the purpose of the visit. LPA spoke with Administrator, Ronan Rance, arrived at 3:38PM. The administrator currently holds a certificate (#6056425740) that expires on 07/15/2024. The facility’s fire clearance was approved for three (3) and three (3) non-ambulatory residents.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of five (5) total bedrooms and two (2 ) bathrooms. One (1) bedroom is occupied by staff. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 70 degrees Fahrenheit. 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 124.5 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. Paper goods are sufficient. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SERENE CARE JACQUELINE
FACILITY NUMBER: 079200967
VISIT DATE: 05/12/2023
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Continued from LIC809.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher purchased 3/1/2023. First aid kit was observed to be complete. Fire drill was last conducted on 3/11/2023.

All three (3) residents' records were reviewed.

The following forms to be updated and submitted to CCLD by 05/19/2023:
  • LIC 500 Personnel Report
  • Client's roster
  • LIC 308 Designation of facility's Responsibility
  • LIC 610E Emergency disaster plan (9 pages)
  • Liability insurance.
  • Updated facility sketch


The following deficiencies were observed:

-At 3:15pm, LPA observed medication in unlocked kitchen drawer.
-At 3:16pm, LPA observed 4 knives in unlocked kitchen cabinet.
-At 4:15pm, LPA observed during record review that none of the residents files contained an appraisal needs and services plan.
-At 4:30pm, LPA observed staff files were incomplete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/12/2023 05:37 PM - It Cannot Be Edited


Created By: Laura Hall On 05/12/2023 at 05:08 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: SERENE CARE JACQUELINE
FACILITY NUMBER: 079200967

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in having knives and a pair of scissors inaccessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2023
Plan of Correction
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Direct Support Staff immediately locked scissors and knives in kitchen cabinet. Deficiency cleared during visit.
Type A
Section Cited
CCR
87465
87465 Incidental Medical and Dental Care

(h) The following requirements shall apply to medications which are centrally stored:

(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in having medications inaccessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2023
Plan of Correction
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Direct Support Professional locked medication in kitchen cabinet immediately. Deficiency cleared during visit.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/12/2023 05:37 PM - It Cannot Be Edited


Created By: Laura Hall On 05/12/2023 at 05:08 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: SERENE CARE JACQUELINE
FACILITY NUMBER: 079200967

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in having personnel records complete and current which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/22/2023
Plan of Correction
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Administrator agreed to complete and make staff files current, and submit a self-certification that it has been done to CCLD by POC date.
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in having an updated appraisal needs and service plan for each resident which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/22/2023
Plan of Correction
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Administrator agreed to prepare an appraisal needs and service plan for each resident and submit a self-certification that it has been completed to CCLD by POC date.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2023


LIC809 (FAS) - (06/04)
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