342700696-5-1-2025-59-AS-TBAS-DG9R25-20250501123745

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700696
Report Date: 05/01/2025
Date Signed: 05/01/2025 12:38:05 PM

Document Has Been Signed on 05/01/2025 12:38 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	MOUNT HOOD SERENITY CARE		FACILITY NUMBER:	342700696
ADMINISTRATOR/ DIRECTOR:	NEPOMUCENO, IRENE		FACILITY TYPE:	740
ADDRESS:	5704 MOUNT HOOD COURT		TELEPHONE:	(916) 617-7601
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95842
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 3	DATE:	05/01/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Staff, Tonya Miles and Administrator Irene Nepomuceno		TIME VISIT/ INSPECTION COMPLETED:	12:45 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	Licensing Program Analyst (LPA) Talwinder Bains arrived on 05/01/25 to conduct the annual inspection. LPA met with staff Tonya Miles and explained the purpose of today's visit. LPA was notified by staff that administrator was not available today to assist with today's visit. LPA Cheyenne Ratajczak and Licensing Program Manager (LPM), Laura Munoz came after short while to assist with today's visit. Administrator Irene Nepomuceno arrived at 11:32 AM. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, and common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. LPA checked the kitchen area for the ability to prepare and store food. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Following issues were observed during today's visit: Medications accessible to residents, Staff working without fingerprint clearance, Department has no access to staff and residents records, no administrator accessible /working during today's visit, accessible knives, chemicals and laundry supplies to residents, and citations were issued as listed on LIC809-D. LPA requested a copy of the LIC308, LIC 500, LIC610E and current liability insurance to be sent to the Department by 05/15/25. Deficiencies were observed and cited per Title 22, CCR Regulations as listed on LIC 809-D. Civil penalties shall be assessed if facility does not comply with POC requirements which were issued today. Exit interview conducted. Copy of this report ,LIC809G and appeal rights were provided.

Laura Munoz	TELEPHONE: (916) 263-4743
Talwinder Bains	TELEPHONE: (916) 263-4700
	DATE: 05/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

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 5

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 of 5

Document Has Been Signed on 05/01/2025 12:38 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MOUNT HOOD SERENITY CARE	FACILITY NUMBER: 342700696
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87309(a)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on facility tour, LPA observed chemicals and knives were accessible in kitchen which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/02/2025
	Plan of Correction
1 2 3 4	Administrator shall letter of understanding of this Regulation and shall train staff regarding this regulation and send proof to Department by POC date- 05/02/25.

Type A

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
1 2 3 4	Based on record review, Department found out that staff, S1 was not fingerprint cleared and was working at the facility for 2 weeks which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/02/2025
	Plan of Correction
1 2 3 4	Licensee will submit a statement of understanding to LPA that all staff must be fingerprint cleared prior to working in the facility. POC due by 05/02/25. Immediate civil penalty of $500.00 was assessed today.

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

Laura Munoz	TELEPHONE: (916) 263-4743
Talwinder Bains	TELEPHONE: (916) 263-4700
	DATE: 05/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 05/01/2025 12:38 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MOUNT HOOD SERENITY CARE	FACILITY NUMBER: 342700696
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87412(f)

Personnel Records

(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on facility tour, staff interviews, staff have no access to residents and staff's records for Department audit, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/15/2025
	Plan of Correction
1 2 3 4	Administrator shall letter of understanding of this Regulation and shall train staff regarding this regulation and send proof to Department by POC date- 05/15/25. Facility will ensure to have residents and staff records accessible per Department audit.

Type B

Section Cited

CCR

87405(d)

Adminstrator - Qualifications and Duties

(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above as facility administrator was not working/accessible during inspection which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/15/2025
	Plan of Correction
1 2 3 4	Licensee shall letter of understanding of this Regulation to Department by POC date- 05/15/25. Licensee shall make sure to have working/accessible administrator per this requirement.

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

Laura Munoz	TELEPHONE: (916) 263-4743
Talwinder Bains	TELEPHONE: (916) 263-4700
	DATE: 05/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 05/01/2025 12:38 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MOUNT HOOD SERENITY CARE	FACILITY NUMBER: 342700696
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as medications closet was found to be open and medications were accessible to residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/15/2025
	Plan of Correction
1 2 3 4	Administrator shall letter of understanding of this Regulation and shall train staff regarding this regulation and send proof to Department by POC date- 05/15/25.

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.

Laura Munoz	TELEPHONE: (916) 263-4743
Talwinder Bains	TELEPHONE: (916) 263-4700
	DATE: 05/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

LIC809 (FAS) - (06/04)

Page: 5 of 5