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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803610
Report Date: 01/14/2025
Date Signed: 01/14/2025 01:30:05 PM

Document Has Been Signed on 01/14/2025 01:30 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 VILLAFACILITY NUMBER:
496803610
ADMINISTRATOR/
DIRECTOR:		REZNIK, AIDAFACILITY TYPE:
740
ADDRESS:477 PETALUMA AVENUETELEPHONE:
(415) 609-3827
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY: 25CENSUS: 19DATE:
01/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:38 AM
MET WITH:Aida Reznik (Licensee)TIME VISIT/
INSPECTION COMPLETED:
01:44 PM
NARRATIVE
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Licensing Program Analysts, (LPAs) Cuadra and Frank arrived unannounced to conduct an Annual Required Inspection and met with Maritza Pray, Back up Administrator and Aida Reznik, Licensee arrived later. Upon LPA's arrival a cart containing cleaning supplies and other items that could pose a risk were observed unattended on the hallway. LPAs inquired with staff and were told that staff was cleaning that part of the facility. However, it took staff ten minutes to come back to take the cart away.

LPA/Licensee initiated a tour of the facility at 9:30 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 was a portable heater in 1 out of 5 rooms inspected. Per Licensee, 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 111.2, 114.8 and 114.9 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 garbage cans do not have well-fitted covers to prevent the spread of any communicable disease (technical violation issued). Facility has at least two days of perishable and one week of non-perishable foods. LPA/Licensee observed that kitchen outside door did not have a screen door to prevent insects and have a conversation with Licensee regarding door screen needed to be installed in the kitchen outside door (technical violation issued). Medications were centrally stored and locked in the medication room. Activity Calendars and Weekly Menus posted. Required postings observed. Annual fees are current. Fire extinguishers were last inspected December 21, 2023. Facility has a centralized smoke alarm and sprinkler system that is maintained by a vendor. The most recent inspection was conducted December 11, 2024. 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 December 5, 2024. Continues on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
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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Document Has Been Signed on 01/14/2025 01:30 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 01/14/2025 at 11:33 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: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Licensee/Administrator did not comply with the section cited above in 4 out of 4 fire extinguishers were not serviced since December 21, 2023 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/15/2025
Plan of Correction
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Licensee/Administrator will contact the Fire Department to have fire extinguisher serviced. Administrator agreed to submit self-certification form as a proof of Correction (POC) that fire extinguisher have been serviced and charged by a fire extinguisher service company or the Fire Department by POC due date of 1/15/2025.
Request Denied
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Licensee/Administrator did not comply with the section cited above in that a cleaning cart with chemicals was left unattended in the residents hallway which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/15/2025
Plan of Correction
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Licensee/Administrator to ensure all chemicals and cleaning agents are inaccessible to residents. Licensee to conduct refresher training and review regulation for all staff. Licensee/Administrator will submit self-certification that chemicals and cleaning agents are inaccessible by POC date of 1/15/2025.
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
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/14/2025 01:30 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 01/14/2025 at 11:33 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: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that two Caregivers (S1) and (S2) were not associated with the facility in Guardian which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/15/2025
Plan of Correction
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Licensee/Administrator to associate S1 and S2 on in the Guardian system and submit proof of doing so by POC due date of 1/15/2025
Request Denied
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above that resident's (R1) had a whole tablet of an unidentifiable medication loose in the medication bin. In addition, resident's (R2) prescription for Aripiprazole had no prescription label on the bottle or in the medication bin. Both incidents pose an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/15/2025
Plan of Correction
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Facility to conduct in-service training for all staff that handles medications to ensure their understanding of medication management that loose medication are not allowed at any time. Training to include the following information: Date, Training Topic, Name/Job Role, and Signatures by POC due date of 1/15/2025
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
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SERENITY VILLA
FACILITY NUMBER: 496803610
VISIT DATE: 01/14/2025
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Continued from LIC809...File review was initiated at 10:00 am. 5 staff files and 5 resident files were reviewed. Staff have required First Aid and CPR certificates and annual continuation training hours were complete. All residents' medical assessments and care plans were updated/signed by a responsible party as required per regulation. Administrator Certificate for Licensee/Administrator Aida Reznik, 6034483740, expires on 4/11/25. During file review, it was revealed that two staff (S1 and S2) were cleared, but they were not associated to the facility, LPA informed Licensee that both staff should never be working and providing care to residents prior to a criminal record clearance or exemption. Civil penalties are being assessed in the amount of $200 for allowing a person to work, reside or volunteer in the facility without a been associated to the facility. Medications and medication records were reviewed. A spot check of Medication and medication records was also conducted at 10:30am LPA/staff observed a loose tablet was found in the container of resident's (R1) medication. Administrator will review medication and their records and will conduct a staff training. Licensee provided the latest pharmacy audit dated December 2024.

During today's visit, LPAs followed up on an incident report submitted to CCL notifying that resident (R3) on 12/30/24 around 1:11am was threatening to call the police on staff, pushing call button non stop, every time staff would answer their calls, R3 pretended that they were sleeping until 5am. R3 called the paramedics, when they arrived it was observed R1 being aggressive, throwing things at staff and paramedics took R3 on 5150. The facility notified R3's responsible parties. According to the Administrator, R3 is currently in the hospital receiving treatment and after their evaluation, it was determined that R3 needs to be relocated in a higher level of care. They are currently working on adequate placement for the resident's care needs to be met.

Licensee/Administrator to submit updates of the following documents by 1/24/25: Designation of Administrative Resposibility (LIC308) & 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.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC809 (FAS) - (06/04)
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