<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700696
Report Date: 05/28/2025
Date Signed: 05/28/2025 11:56:12 AM

Document Has Been Signed on 05/28/2025 11:56 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MOUNT HOOD SERENITY CAREFACILITY NUMBER:
342700696
ADMINISTRATOR/
DIRECTOR:		NEPOMUCENO, IRENEFACILITY TYPE:
740
ADDRESS:5704 MOUNT HOOD COURTTELEPHONE:
(916) 617-7601
CITY:SACRAMENTOSTATE: CAZIP CODE:
95842
CAPACITY: 6CENSUS: 3DATE:
05/28/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator Irene NepomucenoTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 05/28/25, Licensing Program Analysts (LPAs) Talwinder Bains and Lavinia Muscan arrived at the facility unannounced. LPAs met with Administrator Irene Nepomuceno and explained the purpose of the visit. LPAs conducted a case management visit to follow up on items after facility's visit from 05/01/25.

: Department cited facility on 05/01/25 for staff, S1 was working at the facility on 05/01/25 and civil penalty of $500.00 was issued. Record review and staff interview indicated that facility allowed S1 to reside/present at facility after 05/01/25 which is a repeat violation 87355(e), therefore repeat citation was issued. Immediate civil penalty of $1000.00 was assessed today.

:Residents medication closet was found to be open and medications were accessible to residents in care Department assessed penalty for $100.00 per day from 05/16/25 till date (total - $1300.00) since facility did not fulfill POC requirements which were due on 05/16/25. It should be noted that Department will assess future penalties for $100.00 per day till facility comply with POC requirements.

: LPAs observed the facility to have a door stopper propping open the fire door in the hallway which is repeat violation from 05/01/25 visit, therefore repeat citation was issued. Immediate civil penalty of $1000.00 was assessed today.
: Facility could not provide any paperwork related to staff, S1 when asked for department audit, which is a repeat violation of regulation 87412(f),therefore repeat citation was issued. Immediate civil penalty of $1000.00 was assessed today.

As a result of today’s visit deficiency was cited as indicated on LIC809-D. Civil penalties shall be assessed if facility does not comply with POC requirements which were issued today.

Exit interview conducted and a copy of the report, LIC809G and appeal rights was left at the facility.
NAME OF LICENSING PROGRAM MANAGER: Laura Munoz
NAME OF LICENSING PROGRAM ANALYST: Talwinder Bains
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 4
Document Has Been Signed on 05/28/2025 11:56 AM - It Cannot Be Edited


Created By: Talwinder Bains On 05/28/2025 at 10:06 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: MOUNT HOOD SERENITY CARE
FACILITY NUMBER: 342700696

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/29/2025
Section Cited
CCR
87355(e)

1
2
3
4
5
6
7
87355-(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will make sure that all staff must be fingerprint cleared prior to working in the facility. POC due by 05/29/25.
Immediate civil penalty of $1000.00 was assessed today.
8
9
10
11
12
13
14
Based on record review, Department found out that staff, S1 was not fingerprint cleared and was working at the facility which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
06/05/2025
Section Cited
CCR87465(h)(2)

1
2
3
4
5
6
7
87465-(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:
1
2
3
4
5
6
7
Administrator shall train staff regarding this regulation and send proof to Department.
Department assessed penalty for $100.00 per day from 05/16/25 till date since facility did not fulfill POC requirements which were due by 05/16/25.
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the section cited above as medications closet was found to be open and medications were accessible to residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Laura Munoz
NAME OF LICENSING PROGRAM MANAGER:
Talwinder Bains
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/28/2025 11:56 AM - It Cannot Be Edited


Created By: Talwinder Bains On 05/28/2025 at 10:39 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: MOUNT HOOD SERENITY CARE
FACILITY NUMBER: 342700696

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/29/2025
Section Cited
CCR
87203

1
2
3
4
5
6
7
87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Staff immediately closed fire door and stated that the facility will keep it closed.
Administrator shall send a letter of understanding of this regulation by POC date- 05/29/25. Facility shall plan how to stay in compliance with facility's fire clearance plan.
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the section cited above as LPAs observed facility fire door to be propped open with a door stopper which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Immediate civil penalty of $1000.00 was assessed today.
Type B
06/05/2025
Section Cited
CCR87412(f)

1
2
3
4
5
6
7
87412-(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator shall letter of understanding of this Regulation and shall train staff regarding this regulation and send proof to Department by POC date- 06/05/25. Facility will ensure to have staff records accessible per Department audit.
8
9
10
11
12
13
14
Based on staff interviews, staff have no access to staff's ,S1, records for Department audit, which poses/posed a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Immediate civil penalty of $1000.00 was assessed today.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Laura Munoz
NAME OF LICENSING PROGRAM MANAGER:
Talwinder Bains
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2025


LIC809 (FAS) - (06/04)
Page: 4 of 4