347003477-3-14-2024-27-AS-AVIA-D3CQUY-20240314122930

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347003477
Report Date: 03/14/2024
Date Signed: 03/14/2024 12:29:50 PM

Document Has Been Signed on 03/14/2024 12:29 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	SERENITY FAMILY CARE HOME		FACILITY NUMBER:	347003477
ADMINISTRATOR:	VILLANUEVA, MARIA TERESA M		FACILITY TYPE:	740
ADDRESS:	9086 PIAZZA COURT		TELEPHONE:	(916) 681-8630
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY:	4	CENSUS: 0	DATE:	03/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Maria Teresa Villanueva		TIME COMPLETED:	12:45 PM

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On 3/14/24 at 10:30 am Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct a required annual inspection visit. LPA met the licensee/administrator in record Maria Teresa Villanueva and explained the purpose of the visit. Per administrator, facility is COVID-free status. Present during this visit were no residents in care and 1 staff members on duty. Per Maria, they are taking a break from providing care and will not be accepting new admission at this time.

At 10:45am LPA and administrator toured the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, other common areas, and outside of the facility to ensure compliance with Title 22 regulations. Facility is a single-story home with a fire clearance to serve 4 non-ambulatory elderly residents. Facility is approved for 1 hospice residents. LPA observed the bathroom to contain grab bars, non-skid flooring, close lid trash containers and hygiene supplies. Resident bedrooms were observed to be furnished and unoccupied at this time.

The facility common areas are cleaned and furnished. LPA observed the kitchen to be sanitary and free of clutter. Additionally, the kitchen knives and other sharp objects are kept locked. Toxins and cleaning supplies are kept locked in the laundry room. LPA observed the facility to have adequate food supply with at least 2 days’ worth of perishables and 7 days’ worth of non-perishables.

LPA observed the dining room to be free of clutter. The front yard and the backyard are observed to be free of obstruction and well maintained. Additionally, the backyard is furnished with outdoor furniture for outdoor activities. Water temperature was measured at 119*F and room temperature was measured at 72*F. Smoke and carbon detectors were in good working condition. Fire extinguisher was serviced on 1/23/24. Medication storage area was observed to be locked and inaccessible. There are no medications to review at this time since there are no residents residing at this facility at this time. First aid kit was observed to have adequate supplies and accessible to staff.

{Con't on LIC809-C}

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin Villanueva	TELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SERENITY FAMILY CARE HOME	FACILITY NUMBER: 347003477
	VISIT DATE: 03/14/2024

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{Con't from LIC809}

During this inspection 2 former resident files and 2 staffing files were reviewed for regulatory compliance. All files contained required contents including staff training requirements. All staff noted on LIC 500 contained criminal background clearances. Former resident files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required. Facility’s liability insurance is current and update to date per regulatory requirements. LPA observed personal rights poster. Facility has appropriate internet access available for resident use. LPA observed sufficient equipment and supplies to meet activity program needs of residents in care. LPA reviewed facility’s disaster plan to ensure regulatory compliance. Per administrator, they do not keep a record of quarterly fire drills. LPA provided technical assistance to document their quarterly fire drills.

LPA also conducted the inspection using the CARE tool. The facility has an approved infection control plan in place. LPA requested copy of the facility's Liability Insurance, LIC 308 and LIC 500.

Per California Code of Regulations, Title 22 and Health and Safety Codes, no deficiencies were observed during this visit. Interview was held with the Maria Teresa Villanueva and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin Villanueva	TELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

LIC809 (FAS) - (06/04)

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