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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803632
Report Date: 08/25/2023
Date Signed: 08/25/2023 10:45:15 AM


Document Has Been Signed on 08/25/2023 10:45 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: 5DATE:
08/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:36 AM
MET WITH:Joel Trinidad (Licensee)TIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Marisol Cuadra arrived unannounced to conduct an Annual required inspection and was greeted by staff. Licensee Joel Trinidad arrived later.

LPA/Licensee initiated a tour of the facility around 9:00am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Residents rooms were furnished per regulation. Extra hygiene products and linens were available. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Two fire extinguisher was last serviced August 2023. Smoke alarms and carbon monoxide alarms were tested and operational at time of inspection. Last Disaster drill was conducted on 03/23. Working auditory alarms are placed on all exits. Disinfectants and cleaning solutions were stored inaccessible to residents. Required postings were observed. Administrator Certificate for Joel Trinidad, 6022722740, expires on 11/22/24. Medications were centrally stored and locked. Hot water temperature reading was 112.8 and 114.4 degrees which is within regulation. LPA initiated file review at 9:30 am. LPA reviewed five residents files and five staff files. All residents files have a current medical assessment and care plans updated within the last 12 months. Staff records have current First Aid/CPR certificates and additional 20 hours of required training.

At approximate 10:00am LPA/staff conducted a spot check of medication and found resident's (R1 & R2) medications were not current into the Centrally Stored Medication. R1's medication Pravastatin 10mg tab and R2's medication B12 1000mcg vitamin. Licensee agreed to review and update the Centrally Stored Medication Records.
Licensee agreed to submit updates of the following documents by 9/1/23: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500) and Copy of Liability Insurance. 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 copy of this report was given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2023
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 08/25/2023 10:45 AM - 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 BOARD AND CARE
FACILITY NUMBER: 496803632

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interviews wit Licensee. the licensee did not comply with the section cited above by not maintaining a Centrally Stored Medication Log which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2023
Plan of Correction
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Facility to review and update the Centrally Stored Medication Log by POC due date. Licensee will submit self-certification LIC9098 notifying CCL that CSMR its current.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2023
LIC809 (FAS) - (06/04)
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