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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803632
Report Date: 07/27/2021
Date Signed: 07/27/2021 09:56:12 AM

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 BOARD AND CAREFACILITY NUMBER:
496803632
ADMINISTRATOR:TRINIDAD, JOELFACILITY TYPE:
740
ADDRESS:407 CALISTOGA ROADTELEPHONE:
(707) 537-1933
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:6CENSUS: 6DATE:
07/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Licensee/Administrator, Joel TrinidadTIME COMPLETED:
10:10 AM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct an Annual inspection at approximately 8:45 AM, and met with licensee/administrator Joel Trinidad. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon entry LPA was screened for COVID symptoms and asked to sign in by licensee. At primary entrance LPA observed temperature logs and visitor sign-in sheet. LPA conducted walk through of the facility with licensee and observed COVID postings throughout. Mitigation plan has been submitted and approved by Community Care Licensing (CCL).

Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Staff have completed Personal Protective Equipment (PPE) and infection control training through Kaiser. Staff have not been N95 fit tested. High touch surface areas are disinfected daily. Due to current facility census, residents could isolate in their own rooms if they became ill. LPA confirmed licensee has necessary PPE and supplies to support a resident in isolation.

Residents' emergency contact information has been updated and licensee confirmed staff are familiar with 911 procedures and protocols. Toxins are secured and inaccessible in locked garage cabinets. A 30 day supply of medications are stored in a locked kitchen cabinet, making them inaccessible to residents. The facility has a sufficient supply of Personal Protective Equipment (PPE) located in garage. Exit alarms on exit doors were working properly.

Continued on LIC809C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 BOARD AND CARE
FACILITY NUMBER: 496803632
VISIT DATE: 07/27/2021
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Facility is allowing residents to have meals in the dining room. All staff and visitors are required to wear masks and visitation is happening primarily on outdoor patio area.

LPA requested following documents during visit.

LIC 9020
LIC 610E
LIC 308
LIC 500
Administrators Certificate
Control of Property

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021
LIC809 (FAS) - (06/04)
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