507003678-5-16-2023-27-AS-KVIA-CRVLDW-20230516084033

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507003678
Report Date: 05/15/2023
Date Signed: 05/16/2023 08:40:44 AM

Document Has Been Signed on 05/16/2023 08:40 AM - 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	SERENITY HILL RESIDENTIAL CARE HOME		FACILITY NUMBER:	507003678
ADMINISTRATOR:	ABANIA, JACINTA ALENI T.		FACILITY TYPE:	740
ADDRESS:	643 HILL ROAD		TELEPHONE:	(209) 848-2238
CITY:	OAKDALE	STATE: CA	ZIP CODE:	95361
CAPACITY:	12	CENSUS: 8	DATE:	05/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Jacinta Abania, Administrator		TIME COMPLETED:	03:45 PM

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On 05/15/23 at 9:45 AM, an unannounced annual inspection was conducted by Licensing Program Analyst, (LPA), Kimberly Viarella at Serenity Hill Residential Care Home. LPA identified herself and the purpose of her visit to the Facility Administrator and Licensee, Jacinta Abania (certificate # 6001497740, exp. 05/16/24) and a brief interview followed.

Facility reported census was 9 with 3 on hospice. This facility was approved to admit up to 12 residents with a waiver for 5 hospice. Residents with dementia were observed to be in care at this facility.

The tour began in the kitchen. Knives were secured in a locked drawer. LPA checked the food supply and found that there were enough groceries for 2 days of perishable and 7 days of non-perishable items at this time. Toxins were stored in a locked cabinet under the kitchen sink.

Resident medications were kept in a locked closet in the hallway. Each resident had their own container labeled with their name. Policies and procedures regarding the dispensing of medications were reviewed and discussed. LPA observed narcotics locked in a refrigerator in the garage. LPA inspected the First Aid kit. It contained all the required items and was found to be in compliance at this time.

LPA observed the 2 common rooms and adjacent dining area to possess the required furniture, furnishings and lighting to be in compliance at this time. The Designated Facility Administrator led the tour through 8 resident bedrooms. All were in compliance and contained the required drawer/closet space, bed, night stand, chair and lighting. One hospice resident had a half bed rail with the required documentation from their physician. LPA observed grab bars and bath mats/non-skid surfaces in both bathrooms along with paper towels and trash cans with lids.

LPA was shown 2 linen closets that contained sufficient bedding for the residents in care.

LPA observed 2 fire extinguishers, last inspected 02/23/23 by NorCal Fire Inc. Continues on LIC 809C

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SERENITY HILL RESIDENTIAL CARE HOME	FACILITY NUMBER: 507003678
	VISIT DATE: 05/15/2023

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LPA inspected the garage. A locked mini-refrigerator held resident narcotics. LPA witnessed oxygen machines and other medical equipment along with clothing being stored in this area. There was also another locked cabinet that contained toxins, which was out of reach and inaccessible to residents.

LPA performed an inspection of the exterior of the building. All walkways were clear. There was a sitting area with shade located in the front of the facility for residents to enjoy. LPA noted one screen in disrepair and the Designated Facility Administrator had it fixed prior to the completion of the inspection. No citations were given. LPA instructed the locked shed be opened for inspection. It contained overstock items of paper goods and other household items.

LPA performed a records review for 4 staff and 5 residents. At this time, all files were complete and up to date.

There were no deficiencies cited during this visit. Facility Administrator provided LPA with LIC 610, A copy of Liability Insurance, LIC 500, and an updated LIC 308.

A copy of this report was provided.
Exit Interview.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

LIC809 (FAS) - (06/04)

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