455002550-5-15-2024-59-AS-SBEN-D5ATE9-20240515143933

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 455002550
Report Date: 05/15/2024
Date Signed: 05/15/2024 02:39:38 PM

Document Has Been Signed on 05/15/2024 02:39 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	SERENITY GARDENS		FACILITY NUMBER:	455002550
ADMINISTRATOR/ DIRECTOR:	CAIN, BETTY		FACILITY TYPE:	740
ADDRESS:	1233 WILLIS STREET		TELEPHONE:	(530) 605-4033
CITY:	REDDING	STATE: CA	ZIP CODE:	96001
CAPACITY: 30	TOTAL ENROLLED CHILDREN: 0	CENSUS: 22	DATE:	05/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:00 AM
MET WITH:	Jennifer Gama Resident Care Director		TIME VISIT/ INSPECTION COMPLETED:	02:45 PM

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On 05/15/2024 11:00 AM Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Jennifer Gama Resident Care Director acting for administrator (cert #6014210740 exp.03-02-2026) and explained the purpose of the visit. Administrator certificate is current.

LPA Benson and resident care director toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to four (4) resident rooms, common areas, two (2) bathrooms, kitchen, storage areas and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. Staff and resident files were reviewed. Medications were also reviewed. Medication is locked in a locked closet.

The common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. The bathrooms were clean and in good repair. The kitchen was clean and in good repair. Cooking/dining equipment and utensils were present. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food.

The facility was observed to be at a comfortable temperature. First aid kit fully stocked and ready for emergency use. Fire extinguisher fully charged. Smoke detectors are all operational. Hot water temperature measured within required Title 22 regulations of 105 degrees F and 120 degrees F. All employees requiring background checks are cleared. There is a schedule of activities planned for the clients. All required postings are displayed within the facility.

No pools/bodies of water are on the premises. No firearms are on premises. The last disaster drill was conducted and documented on 04-12-24, the facility has been conducting drills every 3 months.

The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, a copy of the report, and appeal rights provided to Jennifer Gama Resident Care Director.

Lauren Crocker	TELEPHONE: (916) 261-4966
Sarah Benson	TELEPHONE: 530-895-5033
	DATE: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

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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Document Has Been Signed on 05/15/2024 02:39 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SERENITY GARDENS	FACILITY NUMBER: 455002550
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

Type B

Section Cited

CCR

87412(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in 2 out of 3 had no TB test on record, 3 out of 3 staff had no employee rights, 3 out of 3 staff had no 1st aid record which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/15/2024
	Plan of Correction
1 2 3 4	Administrator make dr. apt for TB test. Administrator will have all employees complete employee rights and place in employee file. Administrator will have 1st aid training completed and placed in employee file. Administraor will email LPA when complete.

Deficiency Dismissed

Type B

Section Cited

CCR

87506(b)(13)

Resident Records

(b) Each resident's record shall contain at least the following information: (13) Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or the services he needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in 1 or 3 residents had an out dated needs and services palan dated 2021, 2 out of 3 residents had no signed personal rights record, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/15/2024
	Plan of Correction
1 2 3 4	Administrator will have needs and services plan completed and a copy placed in resdent file. Administrator will have personal rights signed and placed in file. Administrator will email LPA when complete.

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: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah Benson	TELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

LIC809 (FAS) - (06/04)

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