336403223-11-15-2024-18-AS-ACAO-DB2UY5-20241115145922

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336403223
Report Date: 11/15/2024
Date Signed: 11/15/2024 02:59:49 PM

Document Has Been Signed on 11/15/2024 02:59 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	SERRANO RESIDENTIAL CARE FOR THE ELDERLY		FACILITY NUMBER:	336403223
ADMINISTRATOR/ DIRECTOR:	FRANCES SERRANO		FACILITY TYPE:	740
ADDRESS:	2710 CYPRESS RD.		TELEPHONE:	(760) 325-1537
CITY:	PALM SPRINGS	STATE: CA	ZIP CODE:	92262
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	11/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:15 PM
MET WITH:	Tarcisa Villarin, Caregiver		TIME VISIT/ INSPECTION COMPLETED:	03:15 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

On 11/15/2024, Licensing Program Analysts (LPAs), Andrei Castillo and Seo Jeon arrived at the facility unannounced to conduct the required annual inspection. Upon entry, LPA was greeted by Caregiver, Tarcisa Villarin and informed her of the purpose of the visit. Licensee, Frances Serrano and Administrator, Melvin LLapitan arrived a few minutes later. At the time of the visit, there was one staff member, and five residents present. LPA conducted a tour of the facility with the Caregiver, reviewed facility documents and conducted interviews. The following is a summary of the visit:

Facility Overview: The facility is a one-story home with six bedrooms and six bathrooms, including an attached carport. Resident bedrooms had the required bedding, furniture, and lighting. Facility sketch, exit routes, personal rights, “If you See Something, Say Something,” LTC Ombudsman, complaint information and emergency phone numbers were observed posted in the facility. There was a designated storage space for the residents and staff files, and it was locked and inaccessible to residents in care.

Infection Control: There were hand hygiene and hand washing stations, and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements.

Physical Plant: Floors, windows, and doors were clean and well maintained. Furniture and fixtures were in good condition. The outdoor area which is a gated backyard was free of hazards and has a shaded area with outdoor furniture. Laundry equipment was in good working condition. LPA observed a fully charged fire extinguisher. Disinfectants, cleaning solutions, and sharp and dangerous objects were securely locked and inaccessible to residents.

Cont. LIC809-C

Rikesha Stamps	TELEPHONE: (951) 212-0616
Andrei Castillo	TELEPHONE: 951-248-2222
	DATE: 11/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SERRANO RESIDENTIAL CARE FOR THE ELDERLY	FACILITY NUMBER: 336403223
	VISIT DATE: 11/15/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The smoke and carbon monoxide detectors were tested and operational, and the hot water temperature was measured at 119°F which is within the required limits. Safety night lights were observed throughout the facility. There were no bodies of water located on the property. According to the Licensee, there are no firearms or ammunition on the premises.

Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods.

Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. Administrator’s license is posted in the facility with an expiration date of 10/01/2025.

Record Review and Resident/Staff Files: LPA reviewed files for three staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Five resident files were reviewed and contained all required documentation.

Health-Related Services/Incidental Medical Services: All resident medications were securely locked. LPA reviewed medications for five residents and found 3 residents' centrally stored medication records were missing for the month of October. Citation was issued.

Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation showing the facility holds monthly fire and earthquake drills, which was last conducted on 10/01/2024. All facility indoor and outdoor passageways and exits were clear of obstructions and or debris. There was a first aid kit with a manual.

An exit interview was conducted, and a copy of this report, LIC809-D and Appeal Rights were reviewed and given to the administrator, Melvin Llapitan.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Andrei Castillo	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 11/15/2024 02:59 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SERRANO RESIDENTIAL CARE FOR THE ELDERLY	FACILITY NUMBER: 336403223
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87465 Incidental Medical and Dental Care (h)The following requirements shall apply to medications which are centrally stored:(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Licensee did not keep centrally stored medication records for the month of October 2024. Based on observation and records review, the licensee did not comply with the section cited above in 3 out of 5 residents which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/22/2024
	Plan of Correction
1 2 3 4	Administrator immediately completed medication records for all 3 residents. Administrator will submit a statement showing all staff are trained on importance of centrally stored medication records by the due date above.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Rikesha Stamps	TELEPHONE: (951) 212-0616
Andrei Castillo	TELEPHONE: 951-248-2222
	DATE: 11/15/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3