342700834-9-8-2020-27-AS-ATUK-BT9NJS-20200908103050

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700834
Report Date: 09/08/2020
Date Signed: 09/08/2020 10:31:53 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	SERENITY CARE VILLA LLC		FACILITY NUMBER:	342700834
ADMINISTRATOR:	JACK, IBIFUBARA THEODORE		FACILITY TYPE:	740
ADDRESS:	7274 PRITCHARD ROAD		TELEPHONE:	(916) 337-3486
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95828
CAPACITY:	6	CENSUS: 0	DATE:	09/08/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:23 AM
MET WITH:	Ibifubara Jack		TIME COMPLETED:	10:14 AM

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	Announced Pre-licensing visit made via Google Duo to this facility on 09/08/2020 and was met by the Applicant, Ibifubara Jack, who was briefly interviewed by LPA Anthony Tuck. It was learned that this facility will be licensed to serve up to (6) residents non ambulatory at any given time. This Applicant was also seeking a program for dementia care and a hospice waiver to accept and retain up to (5) hospice residents at any given time and 1 bedridden. There were no residents in care during today's Pre-licensing visit. Tour of the facility was conducted via Google Duo. Dining area, living area, and all other areas intended for resident use were toured and observed to be furnished and maintained in compliance at this time. Kitchen area was toured. Cabinets and drawers were opened and reviewed by LPA Tuck along with the Applicant. Knives and other sharp utensils were observed to be locked in a cabinet to make them inaccessible to the residents at all times. Food supply for 2-day perishable and 7-day nonperishable quantities were reviewed to make sure that this facility was in compliance at this time. Medication cabinet, located in the hallway area, was toured. First aid kit was observed to be present and contained all required components at this time. A tour of the (6) private resident bedrooms was conducted. It was observed that all resident bedrooms were equipped with direct exits at this time. Furnishings and furniture intended for use by the residents were observed to be sufficient and able to meet the needs of the residents at this time. A tour of the resident bathrooms was conducted. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees. Grab bars and nonskid mats were observed to be present and in compliance at this time. Laundry area was toured. All cleaning agents and detergents were observed to be locked and made inaccessible at this time.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2020

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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SERENITY CARE VILLA LLC	FACILITY NUMBER: 342700834
	VISIT DATE: 09/08/2020

NARRATIVE

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Linen closet, located in the hallway, was observed to contain a sufficient supply of towels and linens able to meet the needs of the residents at this time.
A tour of the exterior grounds was conducted. A review of the facility perimeter fence, side gates, and walkways were observed to be maintained in compliance at this time. Gate latches were reviewed and observed to be missing the pull cord but allowed access for emergency response. All proper posters were posted on walls. All smoke detectors were operational, and the carbon monoxide detector was operational.
The Medication log binder was not prepared, binders for resident records and personnel records were not prepared. A separate thermometer in the freezer and fridge were not present.

There were 5 deficiencies observed during today's Pre-licensing visit.

Component III interview was conducted with the Applicant and completed during today's Pre-licensing visit. The Applicant will correct all deficiencies within 24 hours and send proof of all corrections prior to submission for pre-licensing approval of the facility

Exit Interview

A copy of this report will be emailed to the address of the applicant. The applicant is to print and sign a copy and send back to CCL.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2020

LIC809 (FAS) - (06/04)

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