<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803632
Report Date: 06/16/2022
Date Signed: 06/16/2022 10:25:07 AM


Document Has Been Signed on 06/16/2022 10:25 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 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:
06/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator, Joel TrinidadTIME COMPLETED:
10:30 AM
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) Erik Gonzalez Campos arrived unannounced to conduct a Required-1 Year Inspection. LPA was initially greeted by staff, licensee/administrator, Joel Trinidad arrived shortly.

Upon entry, staff requested LPA fill out COVID screening form and take temperature. LPA conducted walk through of the facility with licensee and observed COVID postings throughout. Facility was a comfortable temperature and exits were free from obstructions. Mitigation plan has been submitted and approved by Community Care Licensing (CCL). LPA and administrator discussed infection control plan due later this month. Licensee/administrator has already written plan and had it available for review during the inspection. Licensee/administrator to submit a copy of it to CCL.

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. Exit alarms on exit doors were working properly.

LPA requested licensee/administrator submit the following documents to CCL: LIC 500, LIC 610E, LIC 9020, LIC 308, Liability Insurance, Admin Certificate, Infection Control Plan

No deficiencies cited during today's inspection. Exit interview conducted with Joel Trinidad.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1