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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003477
Report Date: 05/20/2021
Date Signed: 05/20/2021 04:29:47 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SERENITY FAMILY CARE HOMEFACILITY NUMBER:
347003477
ADMINISTRATOR:VILLANUEVA, MARIA TERESA MFACILITY TYPE:
740
ADDRESS:9086 PIAZZA COURTTELEPHONE:
(916) 681-8630
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:4CENSUS: 3DATE:
05/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:34 AM
MET WITH:Administrator - Maria VillanuevaTIME COMPLETED:
11:30 AM
NARRATIVE
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On 05/20/21 at 9:34AM, Licensing Program Analysts (LPA) Christina Valerio and LPA Suong Teh arrived at this facility unannounced to conduct an annual inspection visit. LPAs met with Administrator Maria Villanueva and explained the purpose of the visit.

LPA Valerio and LPA Teh inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living room, and outside areas of the facility to ensure compliance with Title 22 regulations. LPA also conducted the infection control domain tool.

The facility submitted a LIC 808 mitigation plan, which was approved in February 2021.  LPAs went over latest PINs and mitigation plan. The facility has one central entry point and has implemented screening and sign in procedures at the front of the home. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted at the front door and throughout the facility.  The facility has a designated infection control lead. The facility is able to designated and dedicated a Covid-19 room and designated staff person.

Water temperature reads 115° F in the bathroom and room temperature reads 72° F. LPA observed the facility to have adequate food supply. Resident rooms was sanitary and had the required furniture and furnishings. Smoke and carbon detectors were in good repair. Fire extinguisher was up to date with last check on 01/14/21. Medications were found outside of the locked cabinet. Per Administrator Maria, the medications arrived yesterday and she had not put them away

Per California Code of Regulations, Title 22, deficiencies were observed during this visit and can be found on LIC 809-D. Exit interview was held and a report was given to Maria Villanueva.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SERENITY FAMILY CARE HOME
FACILITY NUMBER: 347003477
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations during facility visit, LPA observed medications not locked up and it was accessible to resident. The licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/21/2021
Plan of Correction
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Licensee agreed to read section 87465(h)(2) and send an e-mail stating she has read the regulation and the incident will not reoccur by POC due date.
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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2021
LIC809 (FAS) - (06/04)
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