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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803640
Report Date: 05/05/2023
Date Signed: 05/05/2023 03:39:50 PM


Document Has Been Signed on 05/05/2023 03:39 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 MANORFACILITY NUMBER:
486803640
ADMINISTRATOR:SALAS, EMMANUEL PATRICIOFACILITY TYPE:
740
ADDRESS:1833 KOLOB DRIVETELEPHONE:
(707) 389-4092
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:6CENSUS: 6DATE:
05/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Emmanuel Patricio Salas, AdministratorTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unnanounced to conduct a Required Annual Inspection and met with Administrator Emmanuel Salas. There are currently 6 residents and 2 caregivers on site.

LPA initiated the tour at 12:45 PM and made the following observations: Facility was a comfortable temperature with thermostat reading at 68 degrees F. Passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in resident bathroom measured at 107.6 degrees F which is within allowable range of 105 to 120 degrees F in faucets used by residents. Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked.

Fire extinguisher was purchased on 04/04/2023. Smoke and Carbon Monoxide detectors were tested during inspection and operational. Exit doors have auditory alert system that were functional at time of visit. Last Disaster Drill was conducted on January 3, 2023. All fees are current as of this time.

Three (3) resident and three (3) staff files were reviewed. Staff have required First aid and CPR certificates. Administrator Certificate for Emmanuel Salas 6037240740 expires October 08, 2023. Medications and medication records were reviewed. Required postings were observed.

There was a well-manicured backyard with user-friendly deck for seniors for temperate weather, with umbrellas accessible.

There were no deficiencies noted 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: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023
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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