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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803610
Report Date: 10/18/2021
Date Signed: 10/18/2021 12:04:37 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 VILLAFACILITY NUMBER:
496803610
ADMINISTRATOR:REZNIK, AIDAFACILITY TYPE:
740
ADDRESS:477 PETALUMA AVENUETELEPHONE:
(415) 609-3827
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY:21CENSUS: 18DATE:
10/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:07 AM
MET WITH:Aida Reznik (Licensee)TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced Annual Required – 1 yr. Infection Control inspection met with Licensee, Aida Reznik and Administrator, Maritza Garcia. LPA conducted a Risk Assessment call with Licensee prior to the visit.

LPA arrived at the facility and had their temperature checked and logged into a sign-in sheet. LPA observed that facility has posters on the front entrance indicating visitors about updated visitor's policy to protect residents in care. Once inside the facility, LPA observed that staff were wearing masks during this visit. LPA/Licensee/Administrator conducted a walk-through of the facility and observed Covid-19 posters that included hand washing signs in restrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer dispensers are located through the facility. Facility has multiple bathrooms that are kept stocked with hand hygiene products. Commonly touched surfaces are disinfected at least three times a day. Facility has designated an outdoor and indoor area for visitation. Facility has a designated isolation apartment on the facility premises for residents that need to isolate and is able to serve meals and deliver medications. Facility staff have been trained on PPE protocols and have been N-95 fit tested. Staff and residents are being monitored daily and facility does document daily screening results in a binder. Facility maintains a 30 day supply of medication.

Facility has a 100% vaccination rate of staff and residents. Facility residents and staff just received vaccine booster. Residents do not typically wear a mask while in the facility, but they do wear masks when in the community. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including masks, face shields, gowns and hand sanitizer. PPE supplies are located in an accessible place for all staff. Facility has submitted their Covid Mitigation Plan and approved on 7/16/21. LPA observed residents engaged in a group activity during inspection. Residents have access to alternative communications as phone calls and video calls with their families.

No deficiencies observed during today's visit.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021
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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