496803720-11-9-2023-21-AS-CCOO-CXEUL5-20231109144010

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803720
Report Date: 11/09/2023
Date Signed: 11/09/2023 02:40:17 PM

Document Has Been Signed on 11/09/2023 02:40 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	SERENITY VILLA II		FACILITY NUMBER:	496803720
ADMINISTRATOR:	REZNIK, AIDA		FACILITY TYPE:	740
ADDRESS:	184 BOAS DR		TELEPHONE:	(415) 609-3827
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95409
CAPACITY:	12	CENSUS: 11	DATE:	11/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Aida Reznik, Licensee		TIME COMPLETED:	02:53 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	At approximately 8:30am Licensing Program Analysts (LPAs) Christi Coppo and Christopher Arnhold arrived unannounced to conduct a required Annual inspection and was greeted by Adriana Guerrero, Caregiver. Licensees Aida and Germain Reznik arrived later at approximately 9:30am. Facility currently has 2 residents on hospice which is allowable per the facility's Hospice Waiver for 4. Facility contact information was reviewed and Licensee verified all contact information is accurate. At approximately 9:00am LPAs and Licensee toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPAs observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered and labeled. Facility has garden and large outside area which is appropriate for outdoor use by residents; it is secured by a completely enclosed fence. Kitchen cabinet containing cleaning supplies was locked. Sharp knives in kitchen are inaccessible to residents. From approximately 9:00am to 10:30am LPAs observed residents engaged in special musical entertainment and staff lead exercise activities. At approximately 2:10pm LPA observed residents again engaged in special musical entertainment. All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had required bath mats and grab bars. Water temperature in sink accessible to residents in care measured at 88.2, 87.3 and 126.7 degrees F which is not within the allowable ranges of 105 to 120 degrees F, per Title 22 regulation 87303(e)(2). Licensee immediately turned down water heater. Licensee was not able to get a consistent temperature reading within regulation. LPAs observed residents to need assistance in restrooms. Licensee has contacted hot water tank installer to address water temperature regulation and delivery. Appointment has been set for week of 11/13/2023. Fire extinguishers were last inspected January 6, 2023. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. All exit doors in resident rooms have auditory alert bells that were functional at time of inspection. Facility’s last quarterly disaster drill was conducted on 10/06/2023. Facility has a backup generator for use during a power outage. Continued on 809C.....

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SERENITY VILLA II	FACILITY NUMBER: 496803720
	VISIT DATE: 11/09/2023

NARRATIVE

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Continued from 809....

At approximately 11:00am LPAs conducted a review of 5 resident and 5 staff records. Files were complete.

Cleaning products and laundry soaps are located in a locked cabinet in the laundry room and inaccessible to residents in care.

At approximately 2:00pm LPA and Licensee conducted a spot check of medication and medication records. Medication is centrally stored in a locked closet located in the foyer next to the kitchen.

Aida Reznik Administrator Certificate 6034483740 expired 04/11/2023; however, certificate is currently in Renewal-Pending status. All fees are current as of this time.

LPA and Licensee discussed Infection Control Plan. Licensee will send copy of Infection Control Plan to CCL within 30 days. LPA and Licensee discussed Emergency Disaster Plan. Licensee confirmed no updates needed.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
Copy of Infection Control Plan

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Licensee and a copy of this report was given.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/09/2023 02:40 PM - 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SERENITY VILLA II	FACILITY NUMBER: 496803720
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(2)

87303(e)(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: Water temperature in sinks accessible to residents in care measured at 88.2, 87.3, and 126.7 degrees F all which are not within the allowable ranges of 105 to 120 degrees F.
	Deficient Practice Statement
1 2 3 4	Based on LPAs and Licensee observation, the licensee did not comply with the section cited above in faucets used by and accessible to residents, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/27/2023
	Plan of Correction
1 2 3 4	Licensee has contacted hot water tank installer to address water temperature regulation and delivery. Licensee will submit repair receipt from water tank installer. Licensee will also submit as proof of correction a 2 week measurement log of water temperature readings, taken once in the morning and once at night, showing temperatures in compliance with regulation 87303(e)(2).

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: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

LIC809 (FAS) - (06/04)

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