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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525002614
Report Date: 06/06/2024
Date Signed: 06/06/2024 12:03:38 PM

Document Has Been Signed on 06/06/2024 12:03 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CASA SERENITY LLC 2FACILITY NUMBER:
525002614
ADMINISTRATOR/
DIRECTOR:		PULEOCHANKIN,RACHELFACILITY TYPE:
735
ADDRESS:810 RIO STREETTELEPHONE:
(530) 727-6069
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY: 16CENSUS: 16DATE:
06/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Rachel Puleo-Chankin - administratorTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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06/06/2024 10:30 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with administrator Rachel Puleo-Chankin and explained the purpose of the visit.

LPA Knight and the administrator toured the facility together to ensure the health and safety of clients in care. Areas toured include but are not limited to sixteen (16) client rooms, common areas, two (2) bathrooms, kitchen, storage areas, office, and back yard. Staff and resident files were reviewed. All employees requiring background checks are cleared.

Bedding, linens, and towels for clients were observed and found to be clean and in good repair. Medication is locked in a cabinet.

The facility was observed to be at a comfortable temperature. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Fire extinguishers fully charged and inspected. Smoke detectors and fire alarm systems are inspected quarterly by Bay Alarm, they conducted the most recent quarterly inspection on May 30, 2024. There are no pools/bodies of water are on premises. Last disaster drill was conducted in March 2024 which was an earthquake drill, the facility conducts fire drill monthly.

A deficiency is being cited as a result of today’s inspection and is documented on the attached LIC9099-D. LPA observed the carpet in the common area TV room to be extremely soiled due to high traffic. LPA observed that exterior door in the downstairs common area is very difficult to open. LPA observed discarded microwave, and cardboard boxes in the atrium of the facility next to the kitchen.

Exit interview conducted and copy of report was provided to administrator Rachel Puleo-Chankin.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2024
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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Document Has Been Signed on 06/06/2024 12:03 PM - It Cannot Be Edited


Created By: Rebecca Knight On 06/06/2024 at 11:48 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CASA SERENITY LLC 2
FACILITY NUMBER: 525002614

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation the licensee did not comply with the section cited above. LPA observed the carpet in the common area TV room to be extremely soiled due to high traffic. LPA observed that exterior door in the downstairs common area is very difficult to open. LPA observed discarded microwave, and cardboard boxes in the atrium of the facility next to the kitchen these items pose a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2024
Plan of Correction
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Licensee agrees to have the carpet in the tv room professionally cleaned, repair the issue with the door that is difficult to open, and dispose of the old microwave and cardboard boxes.
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:Lauren Crocker
LICENSING EVALUATOR NAME:Rebecca Knight
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024


LIC809 (FAS) - (06/04)
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