392700592-7-23-2021-27-AS-ABOE-C57RVV-20210723132210

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700592
Report Date: 07/23/2021
Date Signed: 07/23/2021 01:22:27 PM

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 HOME @ MCKINLEY		FACILITY NUMBER:	392700592
ADMINISTRATOR:	ENRIQUEZ, JAMES LUKE		FACILITY TYPE:	740
ADDRESS:	10350 S. MCKINLEY AVE.		TELEPHONE:	(209) 888-4495
CITY:	FRENCH CAMP	STATE: CA	ZIP CODE:	95231
CAPACITY:	20	CENSUS: 0	DATE:	07/23/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	James Luke Enriquez		TIME COMPLETED:	01:30 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	On 7/23/2021 Licensing Program Analyst (LPA) Ashley Boothe spoke with Administrator regarding facility risk assessment questions. Administrator confirmed no staff or clients have experienced symptoms within the last 10 days. At 11:15 am, LPA arrived unannounced to conduct a required 1-year Annual inspection. LPA met with Administrator and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 20 residents. Current Census 0. Facility has not been cleared yet by San Joaquin County Public Health for water analysis. No estimated time was given for the water treatment to be completed. LPA observed administrator certificate expired on 11/15/2020 and Licensee's administrator certificate expired on 8/9/2018. No other staff are employed by the facility. The facility is to notify the Department once water analysis is complete and the Department will schedule reinspection prior to residents moving in to the facility. LPA observed two of two staff associated and cleared in Licensing Information System. The physical plant was toured inside and outside to ensure the safety. LPA observed resident rooms, restrooms, staff rooms, laundry room, kitchen, dining, activity room, office, and property exterior. LPA observed broken fence, dust and dirt build up on floor, dead insects, spider webs, and overgrown dead foliage outside. LPA observed shattered sliding glass door with broken pieces of glass on the ground. Administrator stated it was vandalized in March. LPA observed a pull alarm system, fire extinguisher inspected on 3/1/2019, smoke and carbon monoxide detectors, and fire sprinkler system last annual inspection conducted in September 2019. The temperature inside the facility was measured at 79F which is within the required range of 68F and 85F, or in areas of extreme heat the maximum shall be 30 F less than the outside temperature. The hot water was measured at 106F which is not less than 105F and not more than 120 *F. LPA observed the centrally stored medications area ready to be locked and inaccessible to residents.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 9

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 HOME @ MCKINLEY	FACILITY NUMBER: 392700592
	VISIT DATE: 07/23/2021

NARRATIVE

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Continued from 809 C.

The first aid kit was found in compliance containing: a current edition of a first aid manual, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution.

LPA observed no food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times.

LPA observed areas to store knives and toxins inaccessible to residents. LPA observed area to store centrally stored medications inaccessible to residents.

LPA received COVID mitigation plan submitted to LPA during visit. No COVID precautionary measures in place as there are no residents on site.

Upon a file review the following items were discussed to be submitted with any changes annually:
Administrative Organization LIC309
Designation of Administrative Responsibility LIC308
Personnel Report LIC500
Qualifications of Administrator/Facility Manager
Control of Property
Emergency Disaster Plan LIC610E
First aid/CPR certificates

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. Civil penalties shall be assessed when the licensee fails to correct the violation and any appropriate extensions to the plan of correction due date. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview held, a copy of report was provided.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021

LIC809 (FAS) - (06/04)

Page: 5 of 9

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 HOME @ MCKINLEY	FACILITY NUMBER: 392700592
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/23/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87203

Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that the fire supression system was lasted inspected for annual inspection in September 2019 and fire instingushers were last inspected on 3/1/2019 which poses an immediate health and safety risk to persons. *Civil Penalty assesed on today's date*
	POC Due Date: 07/24/2021
	Plan of Correction
1 2 3 4	The licensee agrees to submit to LPA date of scheduled inspections by POC due date and proof of inspection upon completion of annual inspection.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021

LIC809 (FAS) - (06/04)

Page: 3 of 9

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 HOME @ MCKINLEY	FACILITY NUMBER: 392700592
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/23/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in that LPA observed a shattered sliding glass door with broken pieces of glass on the ground and administrator stated it was vandalized in March which poses/posed a potential health and safety risk to persons.
	POC Due Date: 08/18/2021
	Plan of Correction
1 2 3 4	The Licensee agrees to repair or replace the sliding glass door and clean up broken glass and submit picture of completed work to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021

LIC809 (FAS) - (06/04)

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