496803610-10-24-2023-21-AS-BMOS-CWXT3X-20231025142302

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803610
Report Date: 10/24/2023
Date Signed: 10/24/2023 09:23:42 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/22/2023 and conducted by Evaluator Marisol Cuadra

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20230922100208

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: 17	DATE:	10/24/2023
		UNANNOUNCED	TIME BEGAN:	08:32 AM
MET WITH:	Erica Campos (staff)		TIME COMPLETED:	09:34 AM

ALLEGATION(S):

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-Facility is not ensuring safety of residents in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cuadra arrived unannounced at the facility and met with staff Erica Campos
to deliver findings regarding the complaint allegation above. Licensee Aida Reznik was not able to come to the facility, but was available by phone and gave authorization for staff to sign the report.

Complaint received on 9/22/2023 alleged that Facility is not ensuring safety of residents in care. Per Reporting Party, the front door to the residence was observed ajar without any alarm sound. The front door leads down five steep steps to the sidewalk and is adjacent to a busy street. Although most of the residents are non-ambulatory, a few can self-propel throughout the building with walkers and wheelchairs, and this poses a significant threat to safety. Upon inquiry to facility staff, apparently, they were not aware of the significant safety issue nearby. The licensee informed LPA that the front entrance door is challenging at times, it expands during the rainy season and shrinks when it’s hot. Per Licensee, the front entrance door is not used as an evacuation route due to residents in care won’t be able to use the stairs.
Continued on LIC9099C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230922100208

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/24/2023

NARRATIVE

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Continue from LIC9099...

Although, two different handymen have been contacted previously to fix the door, and they were not able to fix it, mainly because they don’t see the problem. Based on records provided by the facility, there is receipt# 664164 dated 10/1/2023 for door maintenance. Repair company has verified that service was performed at the facility’s front door and stated that the plate for door latch needed was replaced, because it was loose, redrill new holes, put new screws and reattach the plate. However, the problem might show up soon when the winter comes, and the moisture expands the wood of the door, because they only did a quick fix of the door. The preponderance of evidence standard has been met, therefore the above allegation of Facility is not ensuring safety of residents in care is found to be SUBSTANTIATED. The Health and Safety Code cited on the attached LIC 9099D. Appeal Rights Given

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 21-AS-20230922100208

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/24/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/25/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303(a)Maintenance and Operation- (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services & procedures for the safety and well-being of residents, employees, and visitors. This requirement is not met:	1 2 3 4 5 6 7	The licensee has provided a receipt from repair company dated 10/1/2023 as proof of service. Deficiency is cleared.
	8 9 10 11 12 13 14	Based on records review and interviews conducted with Licensee, the facility did not ensure that front entrance was operating properly, which poses a potential risk to the health and safety of residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC9099 (FAS) - (06/04)

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