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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507003678
Report Date: 04/09/2025
Date Signed: 04/09/2025 11:10:49 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 04/09/2025 11:10 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SERENITY HILL RESIDENTIAL CARE HOMEFACILITY NUMBER:
507003678
ADMINISTRATOR/
DIRECTOR:		ABANIA, JACINTA ALENI T.FACILITY TYPE:
740
ADDRESS:643 HILL ROADTELEPHONE:
(209) 848-2238
CITY:OAKDALESTATE: CAZIP CODE:
95361
CAPACITY: 12CENSUS: 12DATE:
04/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Juris Abania, House ManagerTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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On 04/09/2025, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility unannounced to conduct an annual inspection. LPA Campbell met with Juris Abania, House Manager and explained the purpose of the visit.

Upon entry to the facility, LPA Campbell observed several residents in recliners in the living room watching tv. Other residents remained in their rooms resting. Several licensing documents were posted on the wall such as the administrator's certificate (Jacinta Aleni Abania, #7000249748), facility license, emergency disaster plan, and facility sketch. The physical plant is a one story building with 8 bedrooms, 4 bathrooms and office space. There are two sheds in the backyard for supplies and pets. The facility is licensed to serve 6 non-ambulatory residents, aged 60 and over with an approved hospice capacity of 8. The files for 3 residents were reviewed and were found to be complete. All staff found on the roster were fingerprint cleared.

The thermostat is set at 68 degrees Fahrenheit (F) which is between the required temperatures of
68 degrees F (26 degrees Celsius (C)) and 85 degrees F (30 degrees C). For the safety of residents, LPA Campbell observed that knives, medication and cleaners were locked and inaccessible to clients. The first aid kit contained bandages, tweezers, scissors and thermometer and was complete.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Renee Campbell
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 HILL RESIDENTIAL CARE HOME
FACILITY NUMBER: 507003678
VISIT DATE: 04/09/2025
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Three fire extinguishers were observed in the facility. They were fully charged and were last inspected on 02/24/2025. LPA Campbel observed 2 days of perishable foods and 7 days of non-perishable foods for residents. In the backyard, pathways were unobstructed. One shed was used for yard supplies and ppe and another shed was used to provider shelter for two dogs that belonged to the licensee and house manager.

In regards to prior deficiencies, LPA Campbell observed the updated admission agreement that stated facility refund conditions and the refund conditions in the event of death.

Per California Code of Regulations (CCR's) - Title 22, Division 6, Chapter 8, no deficiencies are being cited.
An exit interview was conducted with Juris Abania, House Manager and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Renee Campbell
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
LIC809 (FAS) - (06/04)
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