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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803640
Report Date: 05/30/2025
Date Signed: 05/30/2025 01:01:47 PM

Document Has Been Signed on 05/30/2025 01:01 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SERENITY CARE MANORFACILITY NUMBER:
486803640
ADMINISTRATOR/
DIRECTOR:		SALAS, EMMANUEL PATRICIOFACILITY TYPE:
740
ADDRESS:1833 KOLOB DRIVETELEPHONE:
(707) 389-4092
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
05/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Emmanuel Salas, Administrator/LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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On 05/30/2025 at approximately 09:30AM, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to conduct 1-Year Required visit of this licensed Residential Care Facility for The Elderly (RCFE). LPA was greeted by Staff, Christian Morales Cervantes. Licensee/Administrator, Emmanuel Salas arrived during visit at approximately 09:50AM. Facility has an approved fire clearance and capacity for 6 non-ambulatory residents and has an approved hospice waiver for 2 individuals. Upon arrival, LPA was informed that there were 5 residents in care and 1 staff member on-site. Facility is a 1 story building with 4 Resident bedrooms, 1 staff bedroom, 2 bathrooms, and common spaces.

At approximately 10:05 AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation.

At approximately 10:15AM, LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted. The garbage bins in the resident room did not have proper cover or lid. Licensee agrees to get lid or cover for the garbage bins in the resident room (Technical Advice given). LPA observed activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Toxins are stored in a locked kitchen cabinets under the sink and cabinets in the laundry room. Water temperature measured 109.6 degrees F and 107.4 which is within regulation between 105- and 120-degrees F at faucets accessible to residents. Fire extinguishers were bought new on 05/20/2025. Carbon Monoxide detectors were present and in order. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure.
Continued on LIC809C...
Victoria BertozziTELEPHONE: (707) 588-5059
Ali DenizTELEPHONE: (707) 588-5087
DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2025
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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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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Document Has Been Signed on 05/30/2025 01:01 PM - It Cannot Be Edited


Created By: Ali Deniz On 05/30/2025 at 12:33 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: SERENITY CARE MANOR
FACILITY NUMBER: 486803640

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Per review of records and interview with staff, the facility hasn't held the disaster drills quarterly as required, and couldn't provide a record of any fire/disaster drills conducted at the facility by staff, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2025
Plan of Correction
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Licensee/Administrator agrees to send CCL written verification that disaster drill will be conducted quartly and facility shall retain records as proof that the disaster drills were conducted. Administration agrees to conduct a drill in by 06/09/2025 and send proof of disaster drill to CCL.
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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (707) 588-5059
Ali Deniz
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (707) 588-5087
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2025


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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SERENITY CARE MANOR
FACILITY NUMBER: 486803640
VISIT DATE: 05/30/2025
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Continued from LIC809...

At approximately 11:10AM, LPA reviewed 3 resident records and found 3 out of 3 residents did have current physician's reports, care plans, signed admission agreements, and physician's orders on file. Medication records are thorough and contained physician's orders for each resident.



At approximately 12:05PM, LPA reviewed 3 staff records. 3 of 3 records did contain documentation of completed training records as required. Evidence of first aid and CPR training were current and/or renewed at the time of the visit.

At approximately 12:50PM, LPA reviewed the facility emergency disaster plan with Licensee. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducted and documented a disaster drill on 02/04/2025. Licensee/Administrator stated that they forgot to get it done and will complete on 05/31/2025(See LIC809D page).

LPA was presented with proof of current CPR & 1st Aid certification for staff. Administrator Certificate is for Emmanuel Salas #7010884740 expires on 10/08/2025.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 10 days of this visit:
LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Resident’s
Copy of Updated Certificate of Liability Insurance

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.

Exit interview conducted. Copy of report, LIC-809D, Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Ali DenizTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC809 (FAS) - (06/04)
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