342701022-6-6-2023-27-AS-CVAO-CSJTQS-20230606145624

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701022
Report Date: 06/06/2023
Date Signed: 06/06/2023 02:56:27 PM

Document Has Been Signed on 06/06/2023 02:56 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 2		FACILITY NUMBER:	342701022
ADMINISTRATOR:	ERIC SERRANO		FACILITY TYPE:	740
ADDRESS:	8774 KELSEY DR.		TELEPHONE:	(916) 661-2940
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY:	6	CENSUS: 5	DATE:	06/06/2023
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	02:21 PM
MET WITH:	Lilibeth Meza		TIME COMPLETED:	03:00 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) Christina Valerio arrived to the facility unannounced to conduct a quarterly case management visit. On 7/14/22, a Non-Compliance Conference was held with the licensee and the Department has increased monitoring as a result of deficiencies that were cited. LPA met with facility staff Jonalyn Gatao, and explained the purpose of the visit. LPA was later met by licensee Lilibeth Meza. Administrator Eric Serrano has an active administrator certificate 6056999740 with an expiration date of 08/26/2024. LPA observed 2 staff on shift and confirmed those individuals were fingerprinted cleared and associated to the facility. LPA and facility staff toured the facility to ensure compliance with Title 22 regulations. 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 appraisal and re-appraisal reminder posted near the living room and in the resident file. Facility has 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. LPA observed 2 staff on shift. 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, singing karaoke, or taking a nap. 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. Facility has a reminder calendar book for all residents in front of their file. Continues on LIC 809 - C...

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023

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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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: 06/06/2023

NARRATIVE

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...Continued from LIC 809

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. Annual forms were requested during annual.
The Facility has implemented use of situational questions or video vignettes as a tool. Last training conducted on: 04/22/23. Next training scheduled on 06/07/23
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: 05/10/23
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: 04/22/23
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. According to record review, no new residents have been admitted in the last 3 months.
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. Licensee stated another training for

Per California Code of Regulations, Title 22, no deficiencies were observed today. Exit interview held with Licensee, and a report was provided. Licensee designated facility staff Jonalyn Gatao to sign as licensee is training her to do administrative work and become a designee.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023

LIC809 (FAS) - (06/04)

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