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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003297
Report Date: 07/21/2022
Date Signed: 07/22/2022 02:45:35 PM

Document Has Been Signed on 07/22/2022 02:45 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:LA SERENA HOUSEFACILITY NUMBER:
347003297
ADMINISTRATOR:VILLAROSA, MARIBELFACILITY TYPE:
740
ADDRESS:8970 LA SERENA DRIVETELEPHONE:
(916) 966-0865
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 6CENSUS: 6DATE:
07/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Mark RodilTIME COMPLETED:
12:20 PM
NARRATIVE
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On 7/21/2022 Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a required annual. LPA met with Caregiver, Mark Rodil, who contacted Licensee, Aida Broines, who informed LPA that she cannot make it and Caregiver can act in her behalf. LPA explained purpose of inspection to Caregiver. LPA observed Caregiver to not have a mask on when LPA entered the facility. LPA informed Caregiver the COVID mask requirement and asked Caregiver to put on a surgical mask.

Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and confirmed the facility does not currently have any positive Covid-19 diagnoses. Additionally, LPA were screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Facility currently has (6) residents. LPA observed (3) residents to be eating in the dining area, (1) resident to be watching television in the common area, (1) resident in the backyard, and (1) resident to be sleeping in his room.

LPA and Caregiver toured the interior of the facility, including (2) shared resident room, (1) private resident room, bathrooms, kitchen, laundry room, staff office and common areas. LPA observed it to be clean and in good repair. LPA observed various Covid posters throughout the facility. In the areas toured no immediate health, safety, or personal rights violations were observed. Inside temperature was observed to be 73*F. LPA observed paper towels, soap, sanitizer and Covid posters and a trash can with lid in the bathrooms. LPA observed ample PPE supply. Sharps, Toxins and medications were secured. LPA observed current Administrator certificates posted. LPA advised Caregiver the CCLD "If You See Something" poster should be reprinted to a bigger size. LPA observed the fire extinguisher to be last serviced on April 10, 2020.

LPA requested a current copy of liability insurance and proof of an up to date fire extinguisher by Friday 7/22/2022.

As a result of this visit, see attached deficiencies . Exit interview conducted and copy of report and appeal rights provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2022
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 is an Amendment of Original Document on 07/25/2022 02:26 PM


Created By: Cassie Yang On 07/21/2022 at 12:03 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: LA SERENA HOUSE
FACILITY NUMBER: 347003297

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation of one caregiver not wearing mask, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2022
Plan of Correction
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Staff will wear face covering/mask when working in the facility.
Licensee will submit a statement of compliance to CCLD.
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:Maribeth Senty
LICENSING EVALUATOR NAME:Cassie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022


LIC809 (FAS) - (06/04)
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