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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803720
Report Date: 10/29/2024
Date Signed: 10/29/2024 12:27:11 PM

Document Has Been Signed on 10/29/2024 12:27 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 IIFACILITY NUMBER:
496803720
ADMINISTRATOR/
DIRECTOR:
REZNIK, AIDAFACILITY TYPE:
740
ADDRESS:184 BOAS DRTELEPHONE:
(415) 609-3827
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 12CENSUS: DATE:
10/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:11 AM
MET WITH:German Sinitsyn, LicenseeTIME VISIT/
INSPECTION COMPLETED:
12:41 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Licensee arrived later.

At approximately 9:30am LPA toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA 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. Kitchen cabinet containing cleaning supplies was locked. Kitchen drawer with sharp knives locked.

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 bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 112.3 degrees F in the kitchen and 108.1 degrees F in room #5 which are both within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected 12/21/2023. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drills were conducted 6/10/2024. LPA advised licensee to be sure to conduct fire drills every quarter. Facility has a backup generator for use during a power outage.

At approximately 11:00am LPA conducted a review of 6 resident records. All required documentation present. At approximately 11:30am LPA conducted review of 5 staff records. LPA discussed modifying training record to include date completed and training certificates to include number of hours completed. All required documentation present.

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SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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: 10/29/2024
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Continued from 809...

At approximately 12:00pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. No deficiencies.

Aida Reznik Administrator Certificate 7010118740 expires 4/11/2025. All fees are current as of this time.



No deficiencies cited.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC809 (FAS) - (06/04)
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