496803610-12-20-2022-21-AS-SHAN-CMATWA-20221220140515

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803610
Report Date: 12/20/2022
Date Signed: 12/20/2022 02:05:29 PM

Document Has Been Signed on 12/20/2022 02:05 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 VILLA		FACILITY NUMBER:	496803610
ADMINISTRATOR:	REZNIK, AIDA		FACILITY TYPE:	740
ADDRESS:	477 PETALUMA AVENUE		TELEPHONE:	(415) 609-3827
CITY:	SEBASTOPOL	STATE: CA	ZIP CODE:	95472
CAPACITY:	21	CENSUS: 16	DATE:	12/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Maritza Pray - 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	Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection and met with Administrator, Maritza Garcia - Pray. Facility currently has 16 residents with 4 on hospice. LPA/Administrator Garcia-Pray initiated a tour of the facility at 8:50 am and made the following observations: 1 out of 6 staff were not associated to facility (see LIC9102 for Technical Advisory). Facility was a comfortable temperature, well lit and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in bathrooms used by residents measured at 112.1, 114.2 and 117.1 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. Closets containing cleaning supplies and other items that could pose a risk were locked and inaccessible to residents. Facility has at least two days of perishable and one week of non-perishable foods. Containers were labeled and covered per regulation. Medications were centrally stored and locked in the medication room. Facility maintains a 30 day supply of medications. Fire Extinguisher was found to be last charged on 11/24/2021 out of required limits of fire safety regulations (see LIC9102 for Technical Advisory) at the time of the visit. Facility has a centralized smoke alarm and sprinkler system that is maintained by a vendor and last inspected September, 2022. Carbon monoxide detector was 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 11/20/2022. During tour, LPA observed a one piece combination bike lock on patio exit gate, that was removed immediately. Facility is being cited for fire clearance safety (see LIC 809D). Facility provides transportation to residents to their medical appointments. Required postings were observed. Continue LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

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 VILLA	FACILITY NUMBER: 496803610
	VISIT DATE: 12/20/2022

NARRATIVE

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Infection Control:
Facility has submitted a mitigation program plan and Infection Control Plan. Residents do not typically wear a mask while in the facility, but they do wear masks when in the community. LPA observed that staff were wearing masks during this visit. Facility has more than a 30 day supply of Personal Protective Equipment (PPE).

In addition, facility has a designated area for visits. Residents have also available Zoom, Facetime, and telephone calls when contacting with family members and others. Staff had all PPE training required on file and have obtained N-95 fit testing. All staff and residents have received COVID boosters.

LPA Hansen reviewed Licensing Information System (LIS) with Administrator who stated that is corrected and updated at this time. LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

LPA was presented with proof of current CPR & 1^st Aid certification for staff.

Administrator Certificate for Licensee/Administrator Aida Reznik, 6034483740, expires on 4/11/23

Facility given 2 TA (Technical Assistance) for staff S1 not being associated to facility and Fire Extinguisher not being checked or changed within Regulation time frame.

Facility is being cited for Fire Clearance violation & **Immediate Civil Penalty assessed in the amount of $500.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. Appeal of Rights Given.

LPA Hansen is requesting Licensee to update and submit the following documents to CCL by 1/6/2023:

LIC 308 Designated

Articles of Corporation

LIC 500 Personnel Summary

LIC 610 Emergency Disaster Plan

LIC 610E-S Supplemental Emergency Disaster Plan for RCFE

LIC 9020 Register of Facility Resident’s

Copy of Administrator Certificate

Copy of Certificate of Liability Insurance

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/20/2022 02:05 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 VILLA	FACILITY NUMBER: 496803610
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Type A

Section Cited

CCR

87203

87203-All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. 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 1 out of 5 emergency exits was locked with a combination lock, inabeling anyone not having the combination the ability to exit. This poses an immediate health, safety risk to persons in care. **Immediate Civil Penalty assessed in the amount of $500.
	POC Due Date: 12/21/2022
	Plan of Correction
1 2 3 4	Licensee to ensure walkways and exits are unobstructed. Licensee to review fire code regulations and submit plan to address wandering residents and safety concerns with outside individuals entering facility within fire clearance regulations.POC due date 12/21/2022.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC809 (FAS) - (06/04)

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