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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336403223
Report Date: 11/03/2021
Date Signed: 11/03/2021 01:55:40 PM

Document Has Been Signed on 11/03/2021 01:55 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SERRANO RESIDENTIAL CARE FOR THE ELDERLYFACILITY NUMBER:
336403223
ADMINISTRATOR:FRANCES SERRANOFACILITY TYPE:
740
ADDRESS:2710 CYPRESS RD.TELEPHONE:
(760) 325-1537
CITY:PALM SPRINGSSTATE: CAZIP CODE:
92262
CAPACITY: 6CENSUS: 6DATE:
11/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Tarcisa Villarin, CaregiverTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control.

LPA Gardner met with Caregiver Tarcisa Villarin. Assigned to the home during time of visit were 6 clients. There are currently no cases of COVID-19 within the facility. Licensee Francis Serrano arrived at the facility during LPA's tour.

During today's visit, LPA Gardner toured the facility and made observations pertaining to the facility's infection control measures. LPA Gardner observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and proper use of face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE and overall infection control. LPA Gardner discussed infection control practices and procedures with Ms. Serrano.

During the inspectio,n LPA Gardner observed medication in a locked drawer, but not in its original prescribed container, thus a Type B deficiency was issued.

An exit interview was conducted and a copy of this report, was reviewed with and provided to Ms. Serrano along with the LIC809-D, and Appeal Rights.
SUPERVISORS NAME: Reyna Lacey
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2021
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 11/03/2021 01:55 PM - It Cannot Be Edited


Created By: Jesse Gardner On 11/03/2021 at 01:23 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SERRANO RESIDENTIAL CARE FOR THE ELDERLY
FACILITY NUMBER: 336403223

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/17/2021
Section Cited

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Incidental Medical and Dental Care - (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
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Based on LPA Gardner's observation of medication not in its original prescribed container even though the medication was in a locked drawer, the licensee did not comply with the section cited above which poses an potential health, safety or personal rights risk to persons 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:Reyna Lacey
LICENSING EVALUATOR NAME:Jesse Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2021


LIC809 (FAS) - (06/04)
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