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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525002342
Report Date: 07/19/2022
Date Signed: 07/19/2022 02:05:53 PM

Document Has Been Signed on 07/19/2022 02:05 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:CASA SERENITY, LLCFACILITY NUMBER:
525002342
ADMINISTRATOR:MEHEW, DARLENEFACILITY TYPE:
735
ADDRESS:100 ORCHARD WAYTELEPHONE:
(530) 529-5114
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY: 16CENSUS: 16DATE:
07/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:43 PM
MET WITH:Darlene Mehew - administratorTIME COMPLETED:
02:30 PM
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7/19/2022 12:45 PM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with administrator Darlene Mehew and licensee Melissa Pritchard and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask, gloves. Additionally, LPA Knight was screened by facility staff.

LPA Knight and Ms. Mehew toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, eight (8) resident bedrooms, four (4) bathrooms, kitchen, and storage areas.

LPA observed the administrator, licensee and two care staff not wearing masks while in the facility. Deficiencies are being cited as a result of todays inspection. Based on the interviews and evidence obtained, the preponderance of evidence standard has been met, therefore, the allegation is found to be SUBSTANTIATED.

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Appeal rights were provided, and an exit interview conducted.

Exit interview conducted and copy of report was emailed to administrator Darlene Mehew
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2022
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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Document Has Been Signed on 07/19/2022 02:05 PM - It Cannot Be Edited


Created By: Rebecca Knight On 07/19/2022 at 01:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: CASA SERENITY, LLC
FACILITY NUMBER: 525002342

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
80072(a)(2)

80072(a)(2) Personal Rights Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observations and interviews adminstrator, licensee,Staff 1 and Staff 2 were observed to be in the facility without wearing a mask, which poses a potential health and safety risk to residents in care.
POC Due Date: 08/09/2022
Plan of Correction
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Licensee and administrator agree to conduct staff training on the state requirements for staff and visitors to wear face coverings while in the facility. Administrator and licensee will immediately enforce these requirements.Proof of training will include staff sign in sheet with dtaes and signatires of all staff.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Troy Ordonez
LICENSING EVALUATOR NAME:Rebecca Knight
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2022


LIC809 (FAS) - (06/04)
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