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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202727
Report Date: 09/25/2024
Date Signed: 09/25/2024 02:17:46 PM

Document Has Been Signed on 09/25/2024 02:17 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:TRANQUILITY HOMEFACILITY NUMBER:
435202727
ADMINISTRATOR/
DIRECTOR:		LUCERO RODRIGUEZFACILITY TYPE:
737
ADDRESS:17343 SERENE DRIVETELEPHONE:
(831) 818-7981
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 4CENSUS: 3DATE:
09/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:55 AM
MET WITH:Lucero Rodriguez TIME VISIT/
INSPECTION COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual required - 1 year inspection. LPA met with Administrator (ADM), Lucero Rodriguez and Director of Operations (DOO), David Sandhu.

During visit, LPA toured the facility with the ADM to include the office, kitchen, living room, storage room, resident bedrooms, bathroom, laundry room, garage, and backyard.

All fire exit routes were free and clear of obstruction. All sharp objects, cleaning solutions, disinfectants, and medications observed locked. Carbon monoxide observed present in the facility. Sprinkler system observed throughout the facility and last inspected in April 14, 2023. Facility temperature maintained at 68 degrees Fahrenheit. LPA observed the facility has operable door alarms. 4 staff present are fingerprint cleared and associated to the facility.

Kitchen cabinet underneath the kitchen sink observed secured. Facility has at least 7 days worth of non-perishables and 2 days worth of perishable foods. Refrigerator temperature maintained at 40 degrees Fahrenheit. Freezer temperature in the kitchen initially maintained at 5 degrees Fahrenheit. LPA advised the freezer temperature should be maintained at 0 degrees Fahrenheit. Staff lowered the temperature of the freezer during visit. Items inside the freezer observed cold and frozen. Items inside the refrigerator observed covered and labeled. Fruits and vegetables observed. The locked storage room contains additional non-perishable foods and fruits. PPE cart observed in the storage room. No chemicals and disinfectants observed co-mingling with the food supply. SEE LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2024
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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: TRANQUILITY HOME
FACILITY NUMBER: 435202727
VISIT DATE: 09/25/2024
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Resident bedrooms observed with bedding, linens, dressers, and adequate lighting. Hot water temperature in the bathroom maintained at 108 degrees F. Hand soap observed available for use. LPA observed the facility replaced the broken toilet paper holder from visit on 07/01/2024 with a standing toilet paper holder. LPA observed the baseboard under the sink was removed.

3 residents files were reviewed. 3 out of 3 residents files contained an admission agreement, physician's report, TB result, updated IPP, personal rights form, consent forms, and safeguard of personal properties and valuables. 3 resident's P&I money, centrally stored medication, and centrally stored medication records were inspected and observed maintained with no issues noted.

3 staff files were reviewed. 2 out of 3 staff files contained an updated 1st aid certification, LIC501, LIC503, and TB information. 1 out of 3 staff files did not contain a LIC501 or job application. DOO states the staff's job application may have not been uploaded in their electronic file and an employee success specialist is looking through the paper file for the record. LPA advised to ensure all staff files are complete electronically. 3 staff files reviewed are fingerprint cleared and associated to the facility. 3 staff has annual training to include 16 hours of emergency intervention. Staff are provided at least 20 hours of continuing education annually.

Emergency drills are completed monthly. The last drill was completed on 09/02/2024 and 09/16/2024. LPA observed the facility has emergency supplies to include an flashlights, batteries, non-perishable foods, and first aid kits.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Lucero Rodriguez and Director of Operations David Sandhu and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC809 (FAS) - (06/04)
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