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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700592
Report Date: 09/08/2022
Date Signed: 09/09/2022 06:59:13 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/09/2022 06:59 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:SERENITY HOME @ MCKINLEYFACILITY NUMBER:
392700592
ADMINISTRATOR:ENRIQUEZ, JAMES LUKEFACILITY TYPE:
740
ADDRESS:10350 S. MCKINLEY AVE.TELEPHONE:
(209) 888-4495
CITY:FRENCH CAMPSTATE: CAZIP CODE:
95231
CAPACITY:20CENSUS: 0DATE:
09/08/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:James EnriquezTIME COMPLETED:
05:00 PM
NARRATIVE
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On 9/8/22 at 2:45pm Licensing Program Analyst Maja Jensen arrived at facility announced to conduct an annual inspection. LPA Jensen originally attempted to conduct the inspection on 8/15/22 however there was no one present at the facility and LPA Jensen was unable to access the facility. The facility was originally licensed in August of 2019 however the facility was unable to open due to an issue with meeting the bacteriological water analysis requirement. LPA Jensen met with Administrator James Enriquez and explained the purpose of today's visit. James hold a current Administrator's certificate # 6050194740 valid through 11/15/22.

The facility has no residents at this time as the Licensee is pending water supply clearance. LPA Jensen toured the facility including but not limited to the kitchen, dining room, bedrooms, entertainment room, laundry room, storage areas and grounds. There is a single designated entry point with a sign in table. The facility contained adequate lighting and was free of odor. The LIC 610E posted on a prominent area in the main hall was reviewed and found to be in compliance. The kitchen contained a designated area for knives that remains locked and inaccessible to residents in care. The facility has a separate medication room that remains locked and inaccessible to residents in care. There are night light throughout the hallways. The bedrooms were determined to be adequately furnished and contained a chair, dresser, lamps and night stand for each resident. There is an adequate supply of linens on hand.

The first aid kits were observed to be complete and contained tweezers, thermometer, scissors, wound dressings and a first aid manual. There is a PPE supply on hand consisting of gloves and masks. The fire extinguisher was last serviced on 7/21/21 and is out of compliance. The water temperature in the bathroom was within the required range of 105-120 degrees.

Continued on LIC 809C...
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022
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 4


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: 09/08/2022
NARRATIVE
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Insect exoskeletons were observed in all rooms. The grounds were observed to be free of debris. The window screens were observed to in good repair. The fence surrounding the property had a missing panel and some loose boards.

The facility is licensed by a Limited Liability Corporation (LLC) which recently underwent a change in Administrative organization. Community Care Licensing was not made aware of the LLC.

Deficiencies are being cited on this day-See corresponding LIC 809-D. An immediate civil penalty is being assessed in the amount of $500.

An exit interview was conducted with James Enriquez and a copy of this report along with appeal rights was emailed to James Enriquez.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/09/2022 06:59 PM - It Cannot Be Edited

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: 09/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/09/2022
Section Cited

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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 was not met as evidenced by:
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LPA Jensen observed that the fire extinguishers were last serviced on 7/21/21 and are out of compliance. This poses an immediate risk to health, safety and personal rights.
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Type B
09/09/2022
Section Cited

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(e) The items below shall be reported to the licensing agency within 10 working days following the occurrence.

(1) The organizational changes specified in Section 80034(a)(2). This requirement was not met as evidenced by:
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A change to the administrative organization-articles of organization was filed with the Secretary of State on 12/9/21 but not reported to CCLD. The EIN has not changed. This poses a potential risk to the health, safety and personal rights of residents or prospective residents in care.
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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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 09/09/2022 06:59 PM - It Cannot Be Edited

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: 09/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/29/2022
Section Cited

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(1) The licensee shall take measures to keep the facility free of flies and other insects. This requirement was not met as evidenced by:
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LPA Jensen observed all facility rooms to have insect exoskeletons present. This poses a potential risk to the health, safety and personal rights to residents in care or prospective residents in care.
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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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4