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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097005648
Report Date: 09/20/2021
Date Signed: 09/20/2021 11:52:53 AM

Document Has Been Signed on 09/20/2021 11:52 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:SERRANO MANORFACILITY NUMBER:
097005648
ADMINISTRATOR:DARYA SELIFANOVFACILITY TYPE:
740
ADDRESS:3618 ARCHETTO DRIVETELEPHONE:
(916) 293-8385
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY: 6CENSUS: 6DATE:
09/20/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Olga GudmacTIME COMPLETED:
12:00 PM
NARRATIVE
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During the dropping off of facility documents, upon exiting the facility, LPA noticed four (4) deadbolt locks located on the front door. One deadbolt was approximately 6' 6" above the floor. In the event of an emergency it would be highly unlikely or impossible that the residents would be able to egress the facility in a timely manner due to the amount of locks and specifically the height which would place it out of reach of most clients. This is a violation of the fire clearance.

See 809-D for deficiency cited.

Civil penalties shall apply.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Michael Smith
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2021
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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Document Has Been Signed on 09/20/2021 11:52 AM - It Cannot Be Edited


Created By: Michael Smith On 09/20/2021 at 11:26 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
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: SERRANO MANOR
FACILITY NUMBER: 097005648

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/21/2021
Section Cited
CCR
87202(a)

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87202-Fire Clearance-All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by: Based on LPA observation, licensee did not maintain the fire clearance as there were 4 deadbolt locks
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Facility shall remove all deadbolt locks except the one directly above the door handle, which is the original, one twist, deadnolt lock. This shall be done within 1 day. LPA will revisit facility to clear this deficiency.
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on the front door including 1 which was approximately 6' 6" above the ground and another that is difficult to open requiring several movements to unlock. Residents will not be able to access this and the other deadbolt locks. This is in violation of this section. This poses an immediate health and safety risk to residents in care.
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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:Laura Munoz
LICENSING EVALUATOR NAME:Michael Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2021


LIC809 (FAS) - (06/04)
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