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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003477
Report Date: 02/10/2022
Date Signed: 02/10/2022 11:15:30 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 FAMILY CARE HOMEFACILITY NUMBER:
347003477
ADMINISTRATOR:VILLANUEVA, MARIA TERESA MFACILITY TYPE:
740
ADDRESS:9086 PIAZZA COURTTELEPHONE:
(916) 681-8630
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:4CENSUS: 3DATE:
02/10/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Maria VillanuevaTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to conduct an annual inspection. LPA confirmed with Administrator that staff or residents have not showed any signs or symptoms of COVID in the last 10 days. LPA Valerio was screened for COVID-19 symptoms with temperature taken and asked to sanitize hands and shoes prior to being allowed entry into the facility.

LPA Valerio discussed PIN 22-07, reviewed facility COVID tracking procedures, and current mitigation plan. Administrators clean multiple times throughout the day and ensure all common areas are sanitized. COVID-19 signs regarding social distancing, hand washing, infection control, and prevention strategies are placed throughout the facility. The facility was observe to have a designated visiting area in the front of the home and under shaded area in the backyard. During the visit, the facility was observed to be following all policies related to vaccinations, visitors, and the health and safety of the residents.

LPA Valerio and staff toured the physical plant inside and out to ensure compliance with Title 22 regulations. All emergency exits were clear from obstructions. LPA observed an emergency supply of food, water, and supplies. Medication cabinet, cleaning supplies, sharps were locked away and inaccessible to residents in care. Hot water was measured at 118.1*F. Room temperature was set to 72*F. All required furniture and furnishings were observed in the resident bedrooms and bathrooms. Resident rooms were clean, organized, and had zero odors. Fire extinguishers were observed to be charged and within compliance with last check on 01/26/2022.

LPA observed updated copies of the Administrator Certifications and training certificates for Maria and Noli. LPA requested documentation to be sent via fax: LIC 308, Liability insurance, LIC 601E, and Administrator Certificates

Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report was left at the facility with Administrator Maria Villanueva and Co-Administrator Noli Villanueva.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
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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