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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208236
Report Date: 12/20/2023
Date Signed: 12/20/2023 03:59:32 PM


Document Has Been Signed on 12/20/2023 03:59 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:SERENITY GARDEN HOMES LLCFACILITY NUMBER:
107208236
ADMINISTRATOR:FLORES, GINA ONAGFACILITY TYPE:
740
ADDRESS:5414 E BALCH AVETELEPHONE:
(408) 712-3040
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY:6CENSUS: 2DATE:
12/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Phoeun Marez, AdministratorTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) L. Padgett arrived unannounced to conduct the Annual inspection. LPA was granted entry to the facility by Staff (S1). S1 called Administrator Phoeun Marez (AD) who arrived shortly thereafter and LPA explained the purpose of the visit. Upon arrival LPA observed R1 watching TV and R2 eating breakfast.
During this visit, LPA and AD toured the facility. Resident rooms contained required furnishings and lighting. LPA observed required items in bathrooms with hot water measured at 114.4 degrees F. Resident hygiene supplies were properly stored and available. The kitchen was toured observed in good repair with necessary items and appliances and sharps/knives were properly stored. LPA observed required food supply and paper products. Medications are centrally stored and locked in filing cabinet in the dining room.
Doors and passageways are unobstructed throughout the facility including outdoors. At 9:37am, in bedroom 1, LPA observed surface bolt at the bottom of the door and a flip lock at the top of this door in addition to the door's deadbolt. In the hallway there is a sliding glass door that had a security bar. LPA called and consulted with Licensing Program Manager (LPM) S. Pidgirny who confirmed that these extra locks should be removed as they present a fire clearance issue. AD called their maintenance staff and the flip, surface and bar locks were removed during this visit. No deficiency will be cited.
Facility First Aid kit is located in the medicine cabinet and was found to contain required items. Sufficient supply of perishable and non-perishable food observed.
Fire Extinguisher located in the kitchen serviced on 3/16/2023 and one in the garage serviced 3/21/23. Smoke and Carbon Monoxide detectors are tested and found to be operational. LPA conducted resident and staff file reviews and interviews. Administrator’s certification was shown to LPA and is current.
At 11:30 a medication error was observed during LPA’s review of R2’s medication log and the MAR. There was no record of one medication logged as either given or refused by R2 in the month of December. Also, the amount of pills remaining in the bottle did not match the record.
...report continued on 809C
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lissett PadgettTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 3 of 9


Document Has Been Signed on 12/20/2023 03:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: SERENITY GARDEN HOMES LLC
FACILITY NUMBER: 107208236

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

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 [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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4
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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lissett PadgettTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023
LIC809 (FAS) - (06/04)
Page: 7 of 9


Document Has Been Signed on 12/20/2023 03:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: SERENITY GARDEN HOMES LLC
FACILITY NUMBER: 107208236

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)


This requirement is not met as evidenced by: During medication audit, 1 medication for R2 was found to contain more pills than the record reflects.
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in out of which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2023
Plan of Correction
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AD will conduct a medication administration and documentation training to all staff. This will be completed by 12/29/2023. AD will email copy of training verification to this LPA.
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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lissett PadgettTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023
LIC809 (FAS) - (06/04)
Page: 9 of 9