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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486802085
Report Date: 04/29/2025
Date Signed: 04/30/2025 09:32:16 AM

Document Has Been Signed on 04/30/2025 09:32 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BUCK SERENITY HOMESFACILITY NUMBER:
486802085
ADMINISTRATOR/
DIRECTOR:		CASTRO, GIDEONFACILITY TYPE:
740
ADDRESS:691 BUCK AVENUETELEPHONE:
(707) 449-8394
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 6CENSUS: 4DATE:
04/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:12 AM
MET WITH:Gideon Castro- Administrator TIME VISIT/
INSPECTION COMPLETED:
03:46 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Christi Coppo and Ethel Contreras arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Gideon Castro. Facility contact information was reviewed.

At approximately 10:00am LPA and Admin toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Kitchen cabinet containing cleaning supplies was locked. Kitchen drawer with sharp knives locked.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathroom did not have required bath mat(Technical). Restrooms did have required grab bar. Facility has two water heaters. Water temperature in sink accessible to residents in care measured at 116.6 degrees F which is within the allowable range of 105 to 120 degrees F. Restroom in room six water measured at 99.01 which is not within the allowable range of 105 to 120 degrees F. Bedroom five had oxygen tanks in which 1 out of 3 were not placed in holder and not strapped to the wall (Technical).

LPAs observed Thick-It thickener stored under stairs made accessible to residents. Thickener prescribed to resident's name that does not match any current residents. Medication fridge unlocked, making medication accessible to residents. Fridge had suppositories (Bisacodyl 10mg) with resident's name that does not match any current residents. Insulin pen without a label inside ziplock bag in also in fridge. (Deficiency cited, see 809D). Medications found to be pre-poured in small plastic containers inside kitchen drawer on left hand side of refrigerator and not in its originally received container. (Deficiency cited, see 809D)

Continued on 809C...

NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Ethel Contreras
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2025
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 9
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BUCK SERENITY HOMES
FACILITY NUMBER: 486802085
VISIT DATE: 04/29/2025
NARRATIVE
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Continued from 809...

Tiles on vanity in bathroom next to room #4 and around left hand side of kitchen sink observed to have dark black substance present in grout as well as broken tile. Deck ramp on wrap around deck has two sections of plywood. Section of plywood in the middle of ramp bows heavily under pressure, cracking sound when stepped on. (Deficiency cited, see 809D).

Fire extinguishers were last inspected 4/1/25. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drills were conducted with each staff member during their respective training days, LPA observed all training dates for respective staff were within the quarter. Facility has a backup generator for use during a power outage.

LPA conducted a review of 4 resident records. All required documentation present. 1/2 rails and crushed meds orders all on file for respective residents.

LPA conducted review of 3 staff records. Health Screening for all staff appeared fabricated. Health Screenings had same exact hand writing and date of visits listed within 3 days of each other. Furthermore, signature of physician appeared to be he same on all screens and lacked date. Additionally, TB test marked as negative but action taken listed as chest X-ray. LPAs discussed appearance of fabrication with admin. Admin denies fabrication. Admin agrees to submit current health screenings with TB clearance to CCL. Three out of three staff had expired first aid expiring on 1/06/2025. Additionally, LPAs attempted verification of first aid certificate numbers via American Red Cross website, unable to locate certificate. (Deficiency cited, see 809D).

Continued on 809C(2)....
NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Ethel Contreras
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 04/30/2025 09:32 AM - It Cannot Be Edited


Created By: Ethel Contreras On 04/29/2025 at 02:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BUCK SERENITY HOMES
FACILITY NUMBER: 486802085

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on LPA and Admin observation , the licensee did not comply with the section cited above in that
Thickener stored under stairs made accessible to residents. Medication fridge unlocked, making medication accessible to residents. Fridge had suppositories(bisacodyl 10mg),and Insulin pen without a label inside ziplock bag in also in fridge.which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2025
Plan of Correction
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Licensee to submiit LIC9098 self certifying that they will lock refridgerated medications by POC due date 4/29/25. Licensee immedietly threw out thickener in trash, no plan of correction needed.
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Admin observation the licensee did not comply with the section cited above in Medications found to be prepoured in small plastic containers and not in its originally received container which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2025
Plan of Correction
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Licensee to submit LIC9098 self certifying that they cannot pre-pour medication by POC due date 4/30/25
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Ethel Contreras
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2025


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 04/30/2025 09:32 AM - It Cannot Be Edited


Created By: Ethel Contreras On 04/29/2025 at 02:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BUCK SERENITY HOMES
FACILITY NUMBER: 486802085

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on LPA and admin observation, the licensee did not comply with the section cited above in that Tiles on vanity in bathroom next to room #4 and around left hand side of kitchen sink observed to have dark black substance present in grout as well as broken tile. Deck ramp on wrap around deck has two sections of plywood. Section of plywood in the middle of ramp bows heavily under pressure, cracking sound when stepped on which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2025
Plan of Correction
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Licensee to submit pictures showing that deck ramp wood replaced and areas around sink clean with tile repaired by POC due date 5/30/25
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Ethel Contreras
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2025


LIC809 (FAS) - (06/04)
Page: 5 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BUCK SERENITY HOMES
FACILITY NUMBER: 486802085
VISIT DATE: 04/29/2025
NARRATIVE
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Continued on from 809-C...

LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked closet. LPAs advised admin to complete prescribing physician;on Centrally Stored Medication Log.

Gideon Castro Administrator Certificate #7004971740 expires 5/19/2026. All fees are current as of this time.



LPA and Administrator discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
Liability Insurance

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator and a copy of this report was given.

LPAs experienced printer issues and was unable to final print, time of completion 3:50pm. LPAs will email copy of report and deficencies.

NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Ethel Contreras
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 04/30/2025 09:32 AM - It Cannot Be Edited


Created By: Ethel Contreras On 04/29/2025 at 02:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BUCK SERENITY HOMES
FACILITY NUMBER: 486802085

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(c)(1)

87411 Personnel Requirements - General (c)All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69(1)staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Admin record review and observation , the licensee did not comply with the section cited above in three out of three: S1,S2, S3 did not have current First AId Certification which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2025
Plan of Correction
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Facility to submit plan to have S1,S2,S3 complete first aid certification by POC due date. Proof of certification to be submitted to CCL by no later than 5/20/25
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Ethel Contreras
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2025


LIC809 (FAS) - (06/04)
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