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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701082
Report Date: 08/06/2024
Date Signed: 08/06/2024 05:26:42 PM


Document Has Been Signed on 08/06/2024 05:26 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:SERENITY HOME CAREFACILITY NUMBER:
502701082
ADMINISTRATOR:SOUXOUAY, MARIA ANGELICAFACILITY TYPE:
740
ADDRESS:1813 ELDER LN.TELEPHONE:
(209) 345-6618
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:6CENSUS: 4DATE:
08/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Maria Angelica Souxouay TIME COMPLETED:
02:15 PM
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On 08/06/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct an annual visit. LPA was greeted by staff member (SM) Alona Bastida and explained the purpose of the visit. LPA asked that SM Bastida call the Facility Designated Administrator at this time to inform them that CCL was present. Shortly after, LPA met with Facility Designated Administrator (FDA), Maria Angelica Souxouay. There was one other staff members present at the time of this visit, Ferdinand Estroba.

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 4. 1 out 4 residents were out at the hospital during the time of this visit.
LPA reviewed 3 resident files. LPA reviewed 3 staff files. 3 out 3 staff files are complete and up to date. The administrator has an active administrator certificate #6016477740 and expires on 04/29/2025.
A tour of the facility was conducted.
Fire extinguisher located by the garage door appeared to have been purchased on 06/08/2024 and had an attached receipt to it.
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.
Common areas were toured. Living room, dining area and all other areas intended for resident use were in compliance and good repair.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SERENITY HOME CARE
FACILITY NUMBER: 502701082
VISIT DATE: 08/06/2024
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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 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.

-LIC 308

-LIC 400

-LIC 500

-LIC 610

Technical assistance was provided for Section 87458.

Based on the observations made during today's visit, there are 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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC809 (FAS) - (06/04)
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