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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209174
Report Date: 11/08/2023
Date Signed: 11/08/2023 03:45:44 PM


Document Has Been Signed on 11/08/2023 03:45 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 ESCALONFACILITY NUMBER:
107209174
ADMINISTRATOR:FLORES, GINAFACILITY TYPE:
740
ADDRESS:363 W ESCALON AVE.TELEPHONE:
(408) 712-3040
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY:6CENSUS: 6DATE:
11/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Phoeun MarezTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) M. Flores arrived at the facility unannounced to conduct a required annual visit. LPA explained the purpose of the visit and was granted entry by Administrator, Phoeun Marez.

The residence was set at 72 degrees F temperature and free of passageway obstructions inside and outside. LPAs observed six bedrooms in the residence. Residents' rooms were toured and inspected. Rooms were found to be clean, and furnishing was in good condition.

Kitchen toured, supply of food observed, and food stored properly for perishable and nonperishable. Medication and knives are locked in the kitchen area. Cleaning supplies are locked and stored in the garage. Smoke detectors and carbon monoxide were checked and operating. Fire extinguishers was serviced on 3/16/2023. Last drill completed on 09/06/23. There was outdoor seating for the residents. Outdoor area was clean and free of obstruction.

Deficiencies are being cited based on LPA observation in accordance with the California Code of Regulations, Title 22, see LIC809D. During record review it was found that S1 was not clear to work in the facility.

During the visit a file review was conducted for residents and staff files. An exit interview was conducted, and a copy of this report was provided to AD1 whose signature confirms receipt.

LPA requested the following updated forms faxed to CCLD by 11/15/23: Designation of Facility Responsibility (LIC308), Administrative Organization (LIC309), Personnel Report (LIC 500), Proof of current Liability Coverage.

SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) -24-0610
LICENSING EVALUATOR NAME: Miriam FloresTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
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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Document Has Been Signed on 11/08/2023 03:45 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 ESCALON
FACILITY NUMBER: 107209174

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and record review, the licensee did not comply with the section cited above in 6 out of 6 residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2023
Plan of Correction
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S1 will not return to work at the facility until fingerprint clearance is received.. Licensee will submit proof to the Department for fingerprint clearance by POC due date.
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and record review, the licensee did not comply with the section cited above in 6 out of 6 residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2023
Plan of Correction
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Licensee will submit a copy of physician's orders to the Department for bedrails requirement for R2 by POC due 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: Sergiy PidgirnyTELEPHONE: (559) -24-0610
LICENSING EVALUATOR NAME: Miriam FloresTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
LIC809 (FAS) - (06/04)
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