486803640-6-19-2024-21-AS-DTOA-D6DSP4-20240619140233

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803640
Report Date: 06/19/2024
Date Signed: 06/19/2024 02:02:38 PM

Document Has Been Signed on 06/19/2024 02:02 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:	7073894092
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94534
CAPACITY:	6	CENSUS: 6	DATE:	06/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:17 AM
MET WITH:	Emmanuel Salas, Administrator		TIME COMPLETED:	02:15 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	On 6/19/2024, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Administrator, Emmanuel Salas. The facility currently provides care for 6 residents, none of which are receiving hospice services and some of which with a diagnosis of dementia. LPA continued with a tour of the facility with Administrator, facility found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers found to be purchased within the year and gauge is still within charged meter. Administrator will be purchasing new extinguishers in August 2024. Smoke and carbon monoxide detectors found throughout the facility, were tested and found to be functioning. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations, with food stored in the kitchen refrigerator found to have appropriate coverings. Staff provide residents with meals according to dietary restrictions with an ample amount of fresh and healthy foods observed. Cleaning supplies and other toxins are safely stored in locked cabinets in the laundry room, garage and under kitchen sinks, all of which were secured upon inspection. Sharps and other kitchen supplies that could pose danger if available to residents were found secured under kitchen cabinet. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings and bedding items. Residents that were awake during the inspection were observed interacting with staff in the common area, outdoor patio and in their bedroom watching television or resting. The facility encourages regular family visits and utilizes outdoor areas for resident exercise and mobility. There are two emergency exits located in the backyard which were found to be unobstructed. There is an outdoor patio with shade and large outdoor space for residents to utilize with exits equipped with ramps for accessibility. Continued onto LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

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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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: 06/19/2024

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LPA conducted a sample file review for 3 residents and found needs & service plans and for two (2) residents in need of updating. In addition, LPA found that one (1) Physician's reports for resident with dementia is not in facility file. However, Administrator confirmed that the medical assessment was conducted in April 2024 and will be requesting the updated copy from the resident's family and placed on facility file. Technical Violations issued. Upon a spot check of medications, LPA found that two prescribed medications were not administered for resident due to resident leaving for day program before medications were given.

Lastly, upon LPA observation and review of CCLD Guardian Background Check, LPA found that staff (I1) was not granted fingerprint clearance but observed working in the facility with residents in care. I1 was immediately removed from the facility and Administrator agrees to follow upon clearances and proper association guidelines.

LPA requested the following documents be sent to CCL by COB 6/26/2024:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance
Control of Property/Rental Agreement

Civil penalty issued under Title 22 Regulation 87355(d)(3) for a total of $100 due to staff not fingerprint cleared.

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

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/19/2024 02:02 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: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(d)(3)

Criminal Record Clearance

(3) The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in a total of one (1) staff not properly fingerprint cleared which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/20/2024
	Plan of Correction
1 2 3 4	Licensee has immediately removed individual I1 from the faciltiy. Licensee also agrees to confirm I1's fingerprint clearance before I1 returns to work for the facility. Deficiency cleared at the time of visit. Civil penalty issued under Title 22 Regulation 87355(d)(3) for a total of $100 due to staff not fingerprint cleared.

Type A

Section Cited

CCR

87465(a)(4)

Incidental Medical and Dental Care Services

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation and medication count, the licensee did not comply with the section cited above in 2 out of 2 medications for resident (R1) which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/20/2024
	Plan of Correction
1 2 3 4	Licensee agrees to submit incident report for missed medication to CCLD within 10-day from 6/19/2024. Licensee also agrees to contact R1's physician indicating any observations or changes of condition. LIC9098 Proof of Correction form to be submitted to CCLD by POC date 6/20/2024 confimring completion of items.

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: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

LIC809 (FAS) - (06/04)

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