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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803610
Report Date: 12/02/2025
Date Signed: 12/02/2025 11:15:45 AM

Document Has Been Signed on 12/02/2025 11:15 AM - 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 VILLAFACILITY NUMBER:
496803610
ADMINISTRATOR/
DIRECTOR:		REZNIK, AIDAFACILITY TYPE:
740
ADDRESS:477 PETALUMA AVENUETELEPHONE:
(415) 609-3827
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY: 25CENSUS: 13DATE:
12/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:38 AM
MET WITH:Aida Reznik (Licensee)TIME VISIT/
INSPECTION COMPLETED:
11:34 AM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required Inspection and met with Erica Campos, Lead Staff and Aida Reznik, Licensee arrived later. There are three residents receiving hospice services. Annual fees are current. Required postings observed.

LPA/staff initiated a tour of the facility at 9:00 am and made the following observations: Facility was a comfortable temperature, well lit and passageways were free from obstructions. Resident rooms were furnished per regulation. There are portable heaters observed in resident's rooms. Per staff, the room is shared by two residents who have different preferences regarding the temperature of the room (technical violation issued). Water temperature in bathrooms used by residents measured at 108.1, 114.8 and 115.3 degrees F which are all within allowable range of 105 to 120 degrees F. Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. However, bathroom's and resident's garbage cans do not have well-fitted covers to prevent the spread of any communicable disease. Last year, LPA discussed with the Licensee the importance of having garbage cans with covers and technical violation was issued. Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked in the medication room. Four out of six fire extinguishers were last inspected January 2025. According to lead staff, it appears like the remaining two fire extinguishers were missed when the vendor came to service the other extinguishers. Facility has a centralized smoke alarm and sprinkler system that is maintained by a vendor. The most recent inspection was conducted November 2025. Carbon monoxide detectors were tested and operational. Exit doors have auditory alerts that were functional at time of visit. Each resident has a pendant to alert staff if the resident needs assistance. Last Disaster Drill was conducted on September 12, 2025.
Continues on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2025
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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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 VILLA
FACILITY NUMBER: 496803610
VISIT DATE: 12/02/2025
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Continued from LIC809...

LPA initiated file review at 9:30 am of 5 staff files and 7 resident files were reviewed. All staff have required First Aid and CPR certificates and annual continuation training hours were complete. All residents' medical assessments were updated. Two out of seven resident's care plans were not signed by their responsible party as required per regulation. Administrator Certificate for Licensee/Administrator Aida Reznik, 7010118740, expires on 4/11/27. Activity Calendars and Weekly Menus posted. Medication and medication records were reviewed.

Licensee previously provided updates of the following: Designation of Administrative Responsibility (LIC308), Personnel Record (LIC500) and Liability Insurance Certificate.

Deficiencies 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.

Exit interview was conducted with Licensee and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/02/2025 11:15 AM - It Cannot Be Edited


Created By: Marisol Cuadra On 12/02/2025 at 11:00 AM
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 VILLA
FACILITY NUMBER: 496803610

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(f)
Maintenance and Operation
(f) All waste shall be located, stored, and disposed of in a manner that will not transmit communicable diseases or odors, pose a risk to health and safety, or provide a breeding place or food source for insects or rodents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/staff observation, interview & record review, the licensee did not comply with the section cited above by not providig garbage cans with cover lids to resident's bedrooms and bathrooms which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2025
Plan of Correction
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Licensee agrees to provide garbage cans with well-fitted covers and will submit self-certification LIC9098 form to CCL by POC due date to clear the citation.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/staff observation, interview and record review, the licensee did not comply with the section cited above in two out of seven resident's care plans were not signed by their responsible parties which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2025
Plan of Correction
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Licensee agrees to have resident's responsible parties sign their care plans and will submit self-certification LIC9098 form to CCL by POC due date to clear the citation.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2025


LIC809 (FAS) - (06/04)
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