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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701022
Report Date: 12/02/2022
Date Signed: 12/02/2022 02:43:25 PM


Document Has Been Signed on 12/02/2022 02:43 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:SERRANO GUEST HOME 2FACILITY NUMBER:
342701022
ADMINISTRATOR:ERIC SERRANOFACILITY TYPE:
740
ADDRESS:8774 KELSEY DR.TELEPHONE:
(916) 661-2940
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 6DATE:
12/02/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
02:04 PM
MET WITH:Eric Serrano TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct a quarterly case management visit due to previous non-compliance issues. LPA met with Administrator Eric Serrano and explained the purpose of the visit.

LPA toured the facility to ensure compliance with Title 22 regulations. LPA observed the shed in the backyard to have medical and chair supplies. No bedding or chairs were observed in the shed. No emergency exits were obstructed. The bedrooms and bathrooms had required furnishings. The facility had a 7 day supply on non-perishable and 2 days of perishables located in the pantry and the refrigerator.

LPA reviewed previous recommendations provided by the Department:
  • Monitor and reassess resident needs and services on a regular basis, update care plans annually and when there is a change in condition. Facility has created a reminder system of when documents need to be updated. LPA observed the reminder system and body check form completed for all residents completed for November 2022 and starting on December 2022.
  • Facility has 2 staff present at time of visit to meet the needs of the residents in care as determined by the needs and services and identified by LPA observation and record review.
  • Update physician’s reports annually or when there is change in condition to meet specific resident’s situation per regulation. Facility has created a reminder system of when documents need to be updated.
  • Residents are provided activities to meet their individual potential as observed by LPA during facility visit. Residents were observed watching television, folding laundry, take a nap, out on a visit, and enjoying snack time.

Continues on LIC 809 - C...
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2022
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: SERRANO GUEST HOME 2
FACILITY NUMBER: 342701022
VISIT DATE: 12/02/2022
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  • Facility has created a reminder or tickler system for the administrator to track when specific documents in resident and staff records need to be updated.
  • A Review of all resident medication lists with their physicians during MD visits has been implemented as observed by Statement by Administrator / Licensee.
  • As facility forms are updated. LIC 500 has been updated and approved by LPA Valerio.
  • The Facility has implemented use of situational questions or video vignettes as a tool during the hiring process to assist in finding qualified staff members. Interview with staff member confirmed that the facility conducted wound training, activities of daily living training, and medication training this year. Staff stated a nurse came to the facility and talked to them about the topics and showed hands-on experience. Last training conducted on: 09/28/22
  • The Facility has conducted regular self-audits and assessments using checklists and the CARE tool that was discussed to assist with maintaining compliance in all areas of the operation of the facility. Date last completed: 07/26/2022
  • The Facility has not utilized the TSP Medication Guide for staff training. Licensee instead has utilized M&D Quinley Professional Services, LLC for training. Licensee has conducted self-assessment of the medication administration procedures at the facility. Date training was completed: 06/28/2022
  • The Facility is utilizing preplacement assessments when considering residents for placement, work to ensure that facility staff are able to meet the needs of all residents in care. According to staff, no new residents have been admitted.
  • An In-service was conducted on 06/14/2022 which Reviewed the Reporting Requirements regulation with facility staff and discussed scenarios, and provided contact # of LPA if staff are unclear on specific incident and duty to report.


Per California Code of Regulations, Title 22, no deficiencies were observed today. Exit interview held with Administrator Eric and staff Jonalyn, and a report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022
LIC809 (FAS) - (06/04)
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