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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804256
Report Date: 09/16/2024
Date Signed: 09/16/2024 12:12:25 PM


Document Has Been Signed on 09/16/2024 12:12 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:SERENE VISTA BOARD AND CAREFACILITY NUMBER:
496804256
ADMINISTRATOR:TRINIDAD, JOELFACILITY TYPE:
740
ADDRESS:184 CALISTOGA RDTELEPHONE:
(707) 755-3946
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:6CENSUS: 5DATE:
09/16/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:04 AM
MET WITH:Joel Trinidad, AdministratorTIME COMPLETED:
12:27 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived announced to conduct a pre-licensing inspection and was greeted by caregiver. Administrator Joel Trinidad arrived later

At approximately 9:30am LPA toured the building and grounds. The facility was found to be clean and at a comfortable temperature. Facility has centralized air conditioning. Facility is a one story residence with four [4] single occupancy rooms and one [1] double occupancy room for a total of five bedrooms, three [3] full bathrooms, and one half bathroom, dining room, living room, and a large backyard. All resident rooms are furnished per regulation with a bed, lamp, dresser, chair and bedside table. Water temperatures read at 106.7 degrees F in the kitchen, 106.1 degrees F in the full bath in hallway, 112.9 degrees F in the half bath in room #4, 110.3 degrees F in the full bath in room #5, and 105.3 in the full bath in room #1 all of which are within regulation of 105 & 120 degrees F.

Facility has sufficient items used for cooking and eating. 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. Cleaning supplies are stored outside in a secured cabinet. Kitchen drawer with sharp knives locked. Facility has areas inside and outside for visiting and activities.

Facility received an approved fire clearance dated May 23, 2024 that allows for up to six [6] ambulatory residents. Emergency exits paths identified on facility sketch clear and free from obstruction. Location of shut off valves present on facility sketch verified by LPA. Fire extinguishers were last inspected 05/23/2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drills were conducted on 8/20/2024. LPA observed required posters for residents rights and required licensing posters.

Joel Trinidad Administrator Certificate 7006973740 expires 11/22/2024. Comp III reviewed and exit interview conducted with Administrator and a copy of this report given. No deficiencies. LPA will submit facility's application for approval.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024
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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