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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200967
Report Date: 05/03/2024
Date Signed: 05/03/2024 01:02:13 PM

Document Has Been Signed on 05/03/2024 01:02 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/
DIRECTOR:		RANCES, RONAN BFACILITY TYPE:
740
ADDRESS:2297 JACQUELINE DRIVETELEPHONE:
(925) 267-9084
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 5DATE:
05/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Josephine Ambagan, CaregiverTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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On 5/3/2024 at 9:25am, Licensing Program Analysts LPAs L. Hall and T. Syess- Gibson conducted an unannounced Annual 1-year required inspection. LPAs met with Josephine Ambagan, Caregiver, and explained the reason for the visit. Administrator, Ronan Rances, arrived at 10:05am. The administrator currently holds a certificate (#6056425740) that expires on 07/15/2024. The facility’s fire clearance was approved for three (3) ambulatory and three (3) non-ambulatory. Hospice waiver for four (4).

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and backyard. The facility consists of five (5) bedrooms and two (2) bathroom. One (1) bedroom #5 is occupied by staff. No bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. A comfortable temperature is maintained at 73 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 120.1 degrees Fahrenheit. Night lights are maintained in hallways and passages. Residents’ bathrooms are equipped with grab bars no and non slip mats. Facility has a 7-day supply of perishables and 2-day non perishable foods available for residents.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2024
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: 05/03/2024
NARRATIVE
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Continued from LIC809C

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 01/09/2024. Emergency Disaster Plan was last posted on 093/15/2024. First aid kit was observed to be complete. Fire drill was last conducted on 2/5/2024.
  • Liability Insurance
  • LIC308 Designation of facility responsibility
  • LIC500 Personnel record


LPAs observed the following deficiencies:
  • At 9:45am, LPAs observed R4 and R5 are residing in ambulatory only rooms.
  • At 9:45am, LPAs observed cameras for R3 and R4 in their bedrooms.
  • At 9:50am, LPAs observed during record review hospice notification was not submitted for R2 and R5.
  • At 10:00am, LPA observed a brick covering hole in bottom of kitchen cabinet.
  • At 10:20am, LPA was informed facility has mice.
  • At 11:00am, LPA observed during record review S4 did not have health screening or TB.

Deficiencies cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy the appeal rights and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/03/2024 01:02 PM - It Cannot Be Edited


Created By: Laura Hall On 05/03/2024 at 12:25 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: 05/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.2(a)(1)
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:

(1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups.

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 resident have personal privacy which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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Caregivers immediately removed cameras from R3 and R4's bedroom. Deficiency cleared during visit.
Type B
Section Cited
CCR
87555(b)(27)
(b) The following food service requirements shall apply:

(27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in having rodents and bricking covering where rodents enter which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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Administrator agreed to hire an exterminator and submit invoice 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: 05/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024


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Document Has Been Signed on 05/03/2024 01:02 PM - It Cannot Be Edited


Created By: Laura Hall On 05/03/2024 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: SERENE CARE JACQUELINE
FACILITY NUMBER: 079200967

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87632(d)(2)
(d) If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver as necessary to ensure the well-being of terminally ill residents and of all other facility residents, which shall include, but not be limited to, the following requirements:
(2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice.

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 submitting a hospice notification for residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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Administrator will review regulation 87632 and submit self-certification that facility have reviewed and will abide by regulation going forward to CCLd by POC date.
Type B
Section Cited
CCR
87412(a)(11)
(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:
(11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in S4 having a health screening and TB test which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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Administrator agreed to have S4 obtain a health screening and TB test and submit a copy 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: 05/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024


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Document Has Been Signed on 05/03/2024 01:02 PM - It Cannot Be Edited


Created By: Laura Hall On 05/03/2024 at 12:39 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: 05/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(1)
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.

(1) Nonambulatory persons.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in having rooms not fire cleared for non-ambulatory residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/04/2024
Plan of Correction
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Administrator will implement a plan to have non-ambulatory residents in proper room or submit an LIC200 and updated facility sketch 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024


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