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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803640
Report Date: 06/29/2021
Date Signed: 06/29/2021 01:15:54 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:SERENITY CARE MANORFACILITY NUMBER:
486803640
ADMINISTRATOR:SALAS, EMMANUEL PATRICIOFACILITY TYPE:
740
ADDRESS:1833 KOLOB DRIVETELEPHONE:
(707) 389-4092
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:6CENSUS: 5DATE:
06/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator, Emmanuel SalasTIME COMPLETED:
01:30 PM
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Licensing Program Analysts (LPA), Farhaan Sarangi and Erik Gonzalez Campos arrived unannounced to conduct a Required 1 Year inspection at approximately 11:45 AM, and met with administrator Emmanuel Salas. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon entry LPAs were screened for COVID symptoms and asked to sign in by administrator. At primary entrance LPAs observed temperature logs and visitor sign-in sheet. LPAs conducted walk through of the facility with administrator and observed COVID postings throughout. Mitigation plan was provided by administrator and approved on site by LPAs.

Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. High touch surface areas are disinfected daily. An empty room is available as well as PPE to support a resident in isolation.

Upon discussion with administrator it was noted that facility was no longer documenting daily temperature of residents or staff. Furthermore, it was noted that staff have not undergone Personal Protective Equipment (PPE) or infection control training. LPAs also observed S1 not wearing a mask. LPAs provided guidance to resume documenting symptoms and temperatures, contact local public health for training, and to ensure proper mask etiquette.

Residents' emergency contact information has been updated and licensee confirmed staff are familiar with 911 procedures and protocols. Toxins are secured and inaccessible in locked hallway closet. A 30 day supply of medications are stored in a locked cabinet, making them inaccessible to residents. The facility has a sufficient supply of PPE and hygiene supplies. All exit alarms on exit doors were working properly. Facility is conducting COVID-19 surveillance testing per CCL guidelines.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: SERENITY CARE MANOR
FACILITY NUMBER: 486803640
VISIT DATE: 06/29/2021
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Facility is allowing residents to have meals in the dining room and furniture is set up for social distancing. Common areas are also set up for social distancing. Visits are occurring both inside the facility as well as on the outdoor patio area.

In addition, during the Required 1 Year inspection, LPAs observed a full bed rail on one resident bed. Per Title 22- 87608(a)(5)(B)- Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. LPAs provided technical assistance (See LIC 9102).

LPAs requested following documents:
LIC 309
LIC 400
LIC 308
LIC 500
LIC 402
Emergency Disaster Plan

LPAs unable to print, will email report and supporting documentation to administrator.

No deficiencies cited during this inspection
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
LIC809 (FAS) - (06/04)
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