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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486802085
Report Date: 02/24/2023
Date Signed: 02/24/2023 11:21:44 AM


Document Has Been Signed on 02/24/2023 11:21 AM - 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:BUCK SERENITY HOMESFACILITY NUMBER:
486802085
ADMINISTRATOR:CASTRO, GIDEONFACILITY TYPE:
740
ADDRESS:691 BUCK AVENUETELEPHONE:
(707) 449-8394
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY:6CENSUS: 4DATE:
02/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Gideon Castro, AdministratorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a REQUIRED 1 Year Annual Inspection and was greeted by staff, who asked LPA to sign in and sanitize hands. The Administrator, Gideon Castro, showed LPA around the facility. There were 3 staff at the time of inspection and 3 residents and 1 respite stay.

This visit is focused on infection control. The facility has submitted an infection control plan, which was approved by Community Care Licensing.

The facility was clean and comfortable temperature, exits were free from obstructions. Bathrooms had grab bars, non-skid mats and outfitted with paper towels and soap. Staff were all observed to be wearing masks, and all visitors are required to wear masks as well. There were three (3) fire extinguishers; last inspected 03/11/2022 and were fully charged. There is a hard-wired fire alarm system as well as individual battery-operated smoke detectors, and two (2) carbon monoxide detectors that were operational. Auditory alarms on all exit doors were functional. All residents rooms were furnished per regulation. Signs were also posted throughout the facility to promote social distancing and hand washing. In the event of a COVID outbreak, the facility is able to isolate and quarantine all residents. Facility has at least a 30 day supply of incontinence and Personal Protective Equipment. All staff and residents are vaccinated and boosted.

There were signs posted for "Oxygen in Use" as one resident is occasionally receiving oxygen. All residents were dressed appropriately and well-groomed. The facility is well-lit and provides a homey atmosphere.

There were no deficiencies found at the time of inspection. No citations issued.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023
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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