507003678-5-21-2024-27-AS-MJEN-D5H249-20240521170331

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507003678
Report Date: 05/21/2024
Date Signed: 05/21/2024 05:03:47 PM

Document Has Been Signed on 05/21/2024 05:03 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 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: 11	DATE:	05/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Jacinta Albania		TIME COMPLETED:	05:15 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 5/21/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required one year annual visit. LPA Jensen met with Administrator Jacinta Abania and explained the purpose of today's visit. The current census is 11. The facility is licensed for 6 non-ambulatory residents and has a hospice waiver for 8. LPA Jensen toured the grounds and observed them to be well maintained. All paths were free of obstruction. There is a shaded area and patio furniture available for residents to enjoy outdoor activities. All window screens were in good repair. There are outdoor activities for residents that include gardening and bird watching. LPA Jensen toured the interior of the facility. At the time of this inspection there was 2 staff members present as well as the Administrator and Licensee. All staff present had criminal background clearance and were associated to the facility. The facility was sanitary and free of odor. All required furniture was present and the furniture and appliances were observed to be in good repair. LPA Jensen observed all required postings displayed in a prominent place. There was adequate lighting throughout including night lights in the hallway. The bathrooms were equipped with grab bars and non-skid mats were available for the shower/bath areas. The bathroom water temperature measured at 117.5 degrees which is within the require range of 105 degrees Fahrenheit to 120 degrees Fahrenheit. The facility thermostat was set at a comfortable temperature for the residents. There is an adequate supply of linens on hand. The first aid kit was determined to be complete. The smoke detector and carbon monoxide detector were observed to be in good working order. There is an indoor sprinkler fire suppression system in place. The emergency disaster plan was reviewed and is current. The fire extinguishers were last serviced in March of 2024 and are compliant. There are generators on site in the event of a power outage. The facility maintains emergency lighting, water and food. LPA Jensen inspected the kitchen and observed a 2 day supply of perishable food and a 7 day supply of non perishable food. All refrigerated food that has been removed from the original packaging was labeled and dated.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 7

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 HILL RESIDENTIAL CARE HOME	FACILITY NUMBER: 507003678
	VISIT DATE: 05/21/2024

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
26
27
28
29
30
31
32

LPA Jensen interviewed 4 clients. 4 of 4 clients stated they were satisfied with all aspects of care. LPA Jensen interviewed 2 of 2 staff members and both were able to answer all questions adequately. LPA Jensen reviewed 3 of 3 staff files and determined the files to be complete and in compliance. 5 of 11 resident files were reviewed. 4 of 11 resident files reviewed contained clauses pertaining to no refund upon death which contradicts the Health Safety Code (HSC) §1569.652. 2 Resident files have physician reports stating the resident is bedridden however the facility lacks fire clearance for bedridden residents. LPA Jensen reviewed the liability insurance and determined it to be current with adequate minimum liability limits.

LPA Jensen requested and received the LIC 500 and LIC 308. Technical assistance was provided on Hospice Care and the Department's Hospice Resource Guide, version date 8/30/2021 was provided. LPA Jensen left the facility for lunch from 2pm to 2:45pm.

Deficiencies are being cited pursuant to the California Code of Regulations (CCR) Title 22, Division 6 and civil penalties are being assessed.

The inspection tool was used during the course of this annual inspection. An exit interview was conducted and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC809 (FAS) - (06/04)

Page: 2 of 7

Document Has Been Signed on 05/21/2024 05:03 PM - It Cannot Be Edited

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 HILL RESIDENTIAL CARE HOME	FACILITY NUMBER: 507003678
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85707(g)(5)(A)

g) Admission agreements shall specify the following: (5) Refund conditions. (A) Facility policy concerning refunds, including the conditions under which a refund for advanced monthly fees will be returned in the event of a resident’s death, pursuant to Health and Safety Code (HSC) section 1569.652. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Jensen's review of 5 resident files, 4 of 5 admission agreements stated no refunds upon death in contradiction of the requirements specified by HCS section 1569.652. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/18/2024
	Plan of Correction
1 2 3 4	The Licensee will correct all admission agreements and have them signed by and distributed to the responsible parties and send an attestation to the Department once complete.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC809 (FAS) - (06/04)

Page: 3 of 7

Document Has Been Signed on 05/21/2024 05:03 PM - It Cannot Be Edited

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 HILL RESIDENTIAL CARE HOME	FACILITY NUMBER: 507003678
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87606(c)

Care of Bedridden Residents

(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/22/2024
	Plan of Correction
1 2 3 4	On this day, the Licensee is submitting documentation for a request to change capacity and requesting 4 bedridden and 8 non-ambulatory. This satifies the plan of correction.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC809 (FAS) - (06/04)

Page: 4 of 7