486803640-5-13-2022-21-AS-CFES-CEDSFZ-20220513135110

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803640
Report Date: 05/13/2022
Date Signed: 05/13/2022 01:51:21 PM

Document Has Been Signed on 05/13/2022 01:51 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	SERENITY CARE MANOR		FACILITY NUMBER:	486803640
ADMINISTRATOR:	SALAS, EMMANUEL PATRICIO		FACILITY TYPE:	740
ADDRESS:	1833 KOLOB DRIVE		TELEPHONE:	(707) 389-4092
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94534
CAPACITY:	6	CENSUS: 6	DATE:	05/13/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Administrator, Emmanuel Salas		TIME COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At approximately 12:30PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct an Annual Inspection visit and was greeted by Administrator, Emmanuel Salas. The inspection is focused on the Infection Control procedures and practices of this facility. Upon arrival at the facility, LPA had their temperature checked and logged. LPA answered a standard COVID-symptom questionnaire. LPA conducted a walk-through of the facility and observed the following: COVID-19 signs were observed at the entry way and throughout the facility. Hand-washing signs were observed in the bathrooms and at sinks. All staff present were observed to be wearing a mask. The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has a cleaning and disinfecting schedule that occurs daily. Facility has at least a 30-day supply of Personal Protective Equipment (PPE) and medication for clients. Staff and Residents are screened daily for COVID-19 symptoms and it is logged into facility binders. Facility has a plan in place if a staffing shortage were to occur. Per Conversation with Administrator, Fire Extinguisher was newly bought last month. Fire alarm system and Carbon Monoxide detector were tested and operational. Continued on LIC-809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022

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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SERENITY CARE MANOR	FACILITY NUMBER: 486803640
	VISIT DATE: 05/13/2022

NARRATIVE

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Continued from LIC-809

LPA and Administrator discussed PIN 21-43-ASC regarding Mitigation Plans and PIN-22-13-ASC regarding Infection Control Plans.

LPA requested the following documents to be submitted to CCL by Close of Business, Wednesday, 5/18/2022:

Updated LIC 500 (Personnel Report)
Updated LIC 999 (Facility Sketch)
Administrator to provide copy of Fire Extinguisher Receipt

During walk-through of facility, LPA observed that the staff room was unsecured and contained 5 bottles of over the counter vitamins and medications. LPA discussed the need to ensure staff rooms are secure to prevent situations like this.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Administrator and Appeal rights were given.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/13/2022 01:51 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SERENITY CARE MANOR	FACILITY NUMBER: 486803640
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(f)(2)

This requirement is not met as evidenced by: the following shall be stored inaccessible to residents with dementia. Over-the-counter medication, nutritional supplements, or vitamins...and disinfectants.
	Deficient Practice Statement
1 2 3 4	Based on LPA's observations, Staff Room was unsecured with vitamins in bottles accessible to residents. Administrator did not comply with the section cited above in five of five vitamin bottles which poses a potential health and safety risk to residents in care.
	POC Due Date: 05/18/2022
	Plan of Correction
1 2 3 4	Administrator to ensure Staff Living spaces are not accessible to residents by keeping Staff Room locked at all times. Administrator to submit Training Inservice reviewing Regulation for all staff with the following information: In-service Training date, In-service Topic, and Training Roster with signatures and job role by POC date 5/18/2022.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022

LIC809 (FAS) - (06/04)

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