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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803720
Report Date: 10/25/2022
Date Signed: 10/25/2022 01:47:48 PM

Document Has Been Signed on 10/25/2022 01:47 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 VILLA IIFACILITY NUMBER:
496803720
ADMINISTRATOR:REZNIK, AIDAFACILITY TYPE:
740
ADDRESS:184 BOAS DRTELEPHONE:
(415) 609-3827
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 12CENSUS: 11DATE:
10/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:German Sinitsyn-Administrator/LicenseeTIME COMPLETED:
02:00 PM
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) Alviso conducted a Required 1-Year inspection and met with staff Oralia Vera. Staff Oralia contacted the Administrator German Sinitsyn. The Administrator arrived shortly after being notified of LPA's arrival to complete an inspection. LPA observed activities going on when entering the facility upon arrival, most residents of the facility were participating. There were eleven (11) residents in care at the facility.
This inspection is focused on the Infection Control procedures and practices of this facility.

Facility has a fire clearance for twelve(12) nonambulatory, of which three(3) may be bedridden. Facility has a hospice approval for four(4) residents. Facility has an approved Dementia Plan of Operation. Licensee has submitted the required Infection Control Plan.
Facility was found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Toxins/cleaners were locked up, and inaccessible to residents in care. Medications were locked up, and inaccessible to residents in care.
All bathrooms had grab bars, and non-slip mat/flooring for bathing as needed. Facility has a sufficient supply of personal protective equipment(PPE). Administrator and the staff on duty all had masks on during the LPA's inspection. LPA discussed information Department PINs regarding visitation, continued screening, infection control procedures in the facility, and requirement of wearing an appropriate mask, staff, and visitors.

The LPA observed that staff were not screening visitors, and had not screened the LPA until the LPA asked staff to do so. LPA asked the staff to screen all visitors as required. LPA reviewed with the staff Oralia the screening requirement, including temperature being taken and ensuring to log all information. This deficiency will be cited, 87405(d)(2) Administrator Qualifications and Duties-see LIC809D.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2022
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 3
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 II
FACILITY NUMBER: 496803720
VISIT DATE: 10/25/2022
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
26
27
28
29
30
31
32
LPA are requesting the following documents be updated and submitted to CCL by 10/31/22:

LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E - Emergency Disaster Plan
LIC999- Facility Sketch-Floor Plan
Copy of Current Liability Insurance
Copy of current Administrator 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 held with Administrator German Sinitsyn.



SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 10/25/2022 01:47 PM - It Cannot Be Edited


Created By: Dina Alviso On 10/25/2022 at 01:18 PM
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 II
FACILITY NUMBER: 496803720

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87405(d)(2)
Administrator Qualifications and Duties- 87405(d)(2) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply:.Knowledge of and ability to conform to the applicable laws, rules and regulations.

This requirement is not met as evidenced by: LPA's observations, staff did not screen the LPA when having them enter the facility or at any time once inside the facility until the LPA requested the staff to screen LPA.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observations, and interview with staff, the licensee did not comply with the section cited above in screening all visitors which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2022
Plan of Correction
1
2
3
4
Licensee to ensure that all staff and all visitors are screened as required, including temperatures being taken, and all information being logged. Licensee to review with all staff the screening procedures and ensure staff are doing the screening as required-hold an inservice with your staff. Proof of correction to follow on 10/31/22. Plan of correction due 10/26/22
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3