502701082-8-27-2023-27-AS-APAA-CV4T5T-20230827142604

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701082
Report Date: 08/25/2023
Date Signed: 08/27/2023 02:26:22 PM

Document Has Been Signed on 08/27/2023 02:26 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	SERENITY HOME CARE		FACILITY NUMBER:	502701082
ADMINISTRATOR:	SOUXOUAY, MARIA ANGELICA		FACILITY TYPE:	740
ADDRESS:	1813 ELDER LN.		TELEPHONE:	(209) 345-6618
CITY:	MODESTO	STATE: CA	ZIP CODE:	95355
CAPACITY:	6	CENSUS: 6	DATE:	08/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Maria Angelica Abella Souxouay		TIME COMPLETED:	03:30 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	On 08/25/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct an annual visit. LPA was greeted by staff member (SM) Ferdinand Estroba and explained the purpose of the visit. LPA was met by SM Lillibeth Sarmiento and asked that SM Sarmiento call the Facility Designated Administrator at this time to inform them that CCL was present. There were 2 other staff members present at the time of this visit, Alona Bastida and Noel Sarmiento. This facility is licensed to serve 6 residents who are 60 and older and can be deemed non-ambulatory. This facility holds a hospice waiver for 6 and has a dementia program on file. Current Census was 6. LPA reviewed 6 resident files. All resident files are current and up to date. LPA reviewed 4 staff files. All staff files are current and up to date. A tour of this facility was conducted. The Administrator has an expired certificate but has renewed their certificate prior to expiration date and is awaiting for a new certificate from the department. Fire extinguisher located by the garage door appeared to have been annually inspected by Jorgenson Co on 05/22/2023. The kitchen area was toured. LPA Pascua observed a sufficient seven days of non-perishable as well as two days worth of perishable food supplies in the main kitchen. Additional perishable supplies were identified in an additional refrigerator located in the garage. Knives and additional cleaning supplies were locked and made inaccessible to the residents at this time. LPA Pascua observed a locked centralized stored medication cabinet located in the dining room. Along with Administrator, the LPA observed, reviewed, and compared resident medication with the medication dispensing logs. First Aid Kit was present and contained all of the required components.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SERENITY HOME CARE	FACILITY NUMBER: 502701082
	VISIT DATE: 08/25/2023

NARRATIVE

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Common areas were toured. Living room, dining area and all other areas intended for resident use were in compliance and good repair.
A tour of the garage was conducted. Additional storage for supplies were stored in cabinets. A washer and dryer were also identified in the garage. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees. Grab bars were present and in good repair.
A tour of the resident bedrooms was conducted. Resident furniture was observed to be sufficient to meet the resident needs at this time. A tour of the staff bedroom was also conducted.

A linen closet was located in the hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time. Additional incontinence supplies were also identified.

The exterior of the physical plant was in good repair with no hazards present. Perimeter fence was observed to be stable and gates were in good repair.

The following forms and documents were requested to be updated and submitted into CCL.

-LIC308

-LIC 400

-LIC 500

-LIC 610

No deficiencies were observed or cited during this annual visit.

An exit interview was conducted and a copy of this report was given to Facility Designated Administrator.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

LIC809 (FAS) - (06/04)

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