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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201663
Report Date: 10/06/2023
Date Signed: 03/12/2024 09:34:54 AM

Document Has Been Signed on 03/12/2024 09:34 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:SERENITY LIVINGFACILITY NUMBER:
107201663
ADMINISTRATOR:JONES, JOSIANEFACILITY TYPE:
740
ADDRESS:2605 W. BARSTOW AVENUETELEPHONE:
(559) 449-0504
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY: 6CENSUS: 0DATE:
10/06/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
08:59 AM
MET WITH:Licensee, Josiane JonesTIME COMPLETED:
10:30 AM
NARRATIVE
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An NCC was conducted on this date. Present at the meeting were: RM Brenda White, LPM See Moua and LPA Mary Garza, Licensee Josiane Jones, Attorney, Jacob Reinhardt and Direct Care Staff, Elaine Saucedo. The following deficiencies are being cited today:

· Based on records review, Licensee Representative Josiane Jones charged the resident $12,000.00 for board and care services when the signed Admission Agreement states the monthly rate for the resident is $6,000.00. A rate increase notice of $800.00 effective 1/1/2020 was in the resident’s file, however, this is no date of when this notice was given to the resident.
· Based on records review, a check of $375.00 was made out to staff Elaine. There is nothing in the resident’s file that documents what services were provided beyond the basic services in the Admission Agreement to warrant the payment.

Deficiencies are cited on the attached 809D per Title 22. Exit interview completed with Licensee, Josiane and . A copy of this report and appeal rights provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2023
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 03/12/2024 09:34 AM - It Cannot Be Edited


Created By: Mary Garza On 10/06/2023 at 09:05 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SERENITY LIVING
FACILITY NUMBER: 107201663

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
10/09/2023
Section Cited
HSC
1569.50(a)(4)

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Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California. Based on records reviewed, facility staff financially abused R1.
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Licensee representative will submit a plan to correct and pay back the overpayment due to the resident. The plan will include the amount due, how restitution will be made and the date it will be made by. Proof of the overpayment will be submitted to the CCL office for review.
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Based on records reviewed, facility staff financially abused R1.
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Deficiency Dismissed
Type B
10/13/2023
Section Cited
HSC1569.657

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For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges.
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Licensee representative and all staff will receive training regarding resident’s personal rights, safeguarding resident’s cash, personal property, and valuables, and Administrator Qualifications and Admission Agreement. Training will be completed by a qualified third party agent/person and will include the dates, times, signatures, and topics. Proof of the trainings will be submitted to the CCL office for review.
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Based on records reviewed, R1 was charged $12,000 when the signed admission agreement states the rate is $6000.00.
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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:See Moua
LICENSING EVALUATOR NAME:Mary Garza
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2023


LIC809 (FAS) - (06/04)
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