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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803720
Report Date: 10/15/2025
Date Signed: 10/15/2025 03:21:50 PM

Document Has Been Signed on 10/15/2025 03:21 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: 12DATE:
10/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:03 AM
MET WITH:LIcensee, German Sinitsyn TIME VISIT/
INSPECTION COMPLETED:
03:36 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 German Sinitsyn arrived later. Facility currently has twelve (12) residents in care none of which are currently on hospice. Aida Reznik Administrator Certificate 7010118740 expires 4/11/27. All fees are current as of this time.

Upon arrival, LPA observed residents restrained in wheelchairs. LPA obtained photographic and video evidence of restraints. LPA observed resident (R1) in wheelchair with gait belt being used as restraint. Gait belt was fastened and threaded with belt release placed behind resident in back of wheelchair, inaccessible to resident to release. LPA observed resident (R2) in wheelchair with fabric belt wrapped around their chest area and tied in a knot behind their wheelchair, inaccessible to resident to release. LPA observed resident (R3) in wheelchair with velcro fabric belt wrapped twice around their chest area and back of wheelchair, secured by velcro and the end of the belt tucked into the back right hand side their wheelchair, inaccessible to resident to release (deficiencies cited, see 809D).

At approximately 10:30am 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 and labeled with opened dates present. LPA observed kitchen cabinet under sink to contain disinfectants and cleaning supplies. Cabinet has magnetic locking mechanism, but lock was malfunctioning at the time of inspection, it was sticking such that when the door closed the lock did not latch. LPA showed malfunction to licensee,

Continued on 809C...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 10/15/2025 03:21 PM - It Cannot Be Edited


Created By: Christi Coppo On 10/15/2025 at 10:29 AM
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: 10/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.2(a)(4)
87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1...residents...shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.

This requirement was not met by licensee as evidenced by: LPA observation of postural support used as a restraint, which poses an immediate health, safety or personal rights risk to persons in care.

Deficient Practice Statement
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Based on LPA observation and interview, the licensee did not comply with the section cited above in that LPA observed postural support used as a restraint on R1, R2, and R3, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2025
Plan of Correction
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Facility to submit plan to register all staff to particiapte/attend the ombudsman program for personal rights. Facility to submit plan to contact the local ombusdman to facilitate personal rights trainign for all staff by plan of correction due date. Facility to get the date of the next soonest personal rights training and provide the date to CCL by no later than 10/23/25. Once attendance/ particiaption is completed facility to submit training certificate or record showing all staff in attendance, hours of attendance, date of attendance, and instructor name. Training to be completed no later than December of 2025.
Type A
Section Cited
CCR
87608(a)(4)
87608 Postural Supports (a)...Postural supports may be used under the following conditions. (1) ....used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc.

This requirement not met by licensee as evidenced by LPA observation of postural support used as a restraint, which poses an immediate health, safety or personal rights risk to persons in care.

Deficient Practice Statement
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Based on LPA observation and interview, the licensee did not comply with the section cited above in that LPA observed postural supports used as restraints on R1, R2, and R3, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2025
Plan of Correction
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Admin to submit LIC9098 self-certifying all facility staff will immediately cease using postural supports as a restraint by plan of correction due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2025


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: 10/15/2025
NARRATIVE
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Continued from 809...

licensee got the lock to function properly but licensee will purchase new lock and replace. All other cleaning products and laundry soaps were found inaccessible to residents in care.

All bedrooms were equipped with lighting, night stand, and chest of drawers. Lamp in room #8 functions but light bulb wiring loose and could present as a hazard. LPA showed licensee potential hazard; licensee discarded lamp and will replace. All bedrooms were clean and in good repair. However, LPA noticed strong smell of feces in closet of room #7. LPA found source of feces smell in drawer of night stand located in the closet. Bottom drawer had a pile of feces approximately 3 inches high and 6 inches long, covering the entire back right hand corner of the drawer. Pile of feces had some areas of crusting (deficiency cited, see 809D).

Extra hygiene products and linens were available. Resident bathrooms had required bath mats and grab bars. Water temperature in sinks measured at 111.4 degrees F in the kitchen, 113.7 degrees F in the bathroom of room #2, and 112.4 in the bathroom of room #3, all of which are within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected 1/15/25. Smoke/Carbon Monoxide detectors located throughout the facility were operational. Facility has hardwired fire alarm which is serviced by vendor, last date of service was June 2025 per sticker on box. Facility’s last quarterly disaster drill was conducted on 9/2/25. Facility has a backup generator for use during a power outage.

At approximately 12:00pm LPA conducted a review of six (6) out of twelve (12) resident files. No deficiencies cited.

At approximately 1:45pm LPA conducted a review of six (6) of eight (8) staff records. No deficiencies cited.

At approximately 2:30pm LPA and Licensee conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet located in the kitchen. LPA discussed with licensee ensuring that all discontinued medication orders are maintained on file. No deficiencies cited.

Continued on 809C(2)...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
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: 10/15/2025
NARRATIVE
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Continued form 809C...

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

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.
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/15/2025 03:21 PM - It Cannot Be Edited


Created By: Christi Coppo On 10/15/2025 at 02:58 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: 10/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and licensee observation, the licensee did not comply with the section cited above in that pile of feces was located in bottom drawer of small nightstand in closet of room #7, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2025
Plan of Correction
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Facility to submit LIC9098 self-certifying all staff will keep facility free from incontinence and incontinence odors at all times.
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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2025


LIC809 (FAS) - (06/04)
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