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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202795
Report Date: 06/07/2022
Date Signed: 06/07/2022 11:14:30 AM

Document Has Been Signed on 06/07/2022 11:14 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:SERENITAS CARE, LLCFACILITY NUMBER:
435202795
ADMINISTRATOR:SUNGLAO, BERNARDINOFACILITY TYPE:
740
ADDRESS:677 SHAWNEE LANETELEPHONE:
(408) 677-3635
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 6DATE:
06/07/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Anna ZarragaTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) David Marrufo, Licensing Program Manager (LPM)Sarah Yip, and Program Clinical Consultant (PCC) Nurse Roxane Fangon conducted a tele-visit via Zoom to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility and met with facility staff Anna Zarraga.

Anna Zarragal reports that there are currently 4 COVID-19 positive residents and 1 COVID-19 positive staff.

During today's tele-visit, PCC Nurse Cristina Wong made the following recommendations to the facility:

1. Staff need to know the needs of the residents, including the names of the day programs of the residents.
2. Have staff fit tested for N95 masks.
3. Review PIN 22-04-CCLD.
4. Use symptom screening form at visitor screening area.
5. Disinfect thermometer after each use.
6. Implement a staff screening area.
7. Do not use or keep cloth towels for drying hands
8. Use liquid soap instead of bar soap.
9. Staff should be instructed to keep residents at home away from day program if they have have symptoms
10. Review correct sequence of donning and doffing PPE with staff.
11. Make PPEs accessible to staff when entering isolation rooms

No deficiencies were cited as per California Code of Regulations, Title 22.

This report was reviewed with with Anna Zarraga. A copy of the report will be sent to them for it be signed and returned to CCL.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2022
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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