425802117-8-31-2023-29-AS-JOLN-CV8V4Q-20230831160642

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425802117
Report Date: 08/31/2023
Date Signed: 08/31/2023 04:07:42 PM

Document Has Been Signed on 08/31/2023 04:07 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	SERENE VILLA SENIOR CARE		FACILITY NUMBER:	425802117
ADMINISTRATOR:	BAUTISTA, SUNNY		FACILITY TYPE:	740
ADDRESS:	1935 NOROESTE AVE		TELEPHONE:	(805) 346-1950
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93458
CAPACITY:	6	CENSUS: 2	DATE:	08/31/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Sunny Bautista, Administrator		TIME COMPLETED:	04:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Jenny Olson arrived unannounced to conduct a one year required annual inspection. LPA met with Backup Administrator and explained the reason for the visit. Administrator arrived at the facility around 2:35pm.

Records: LPA reviewed client and staff records at 1:00 p.m. LPA reviewed two (2) resident files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, and current needs and services plan. All files were complete.

LPA reviewed four (4) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, current first aid certification.

CARE TOOLS: LPA and Administrator started part of the CARE Tools.

Due to time constraints LPA was unable to finish the annual and will return at another date to continue the annual inspection.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview completed, copy of report and appeal rights were printed.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

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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Document Has Been Signed on 08/31/2023 04:07 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SERENE VILLA SENIOR CARE	FACILITY NUMBER: 425802117
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(k)

Criminal Record Clearance

(k) The licensee shall maintain documentation of criminal record clearances or criminal record exemptions of volunteers that require fingerprinting and non-client adults residing in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in one non-client adult occasionally resides in the faciility due to convience for school and does not have a criminal record clearance, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/31/2023
	Plan of Correction
1 2 3 4	Administrator agreed to remove adult from the facility until criminal record clearance is obtained. POC is corrected during the time of the visit.

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: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

LIC809 (FAS) - (06/04)

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