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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202795
Report Date: 08/09/2024
Date Signed: 08/09/2024 04:07:39 PM

Document Has Been Signed on 08/09/2024 04:07 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:SERENITAS CARE, LLCFACILITY NUMBER:
435202795
ADMINISTRATOR/
DIRECTOR:		SUNGLAO, BERNARDINOFACILITY TYPE:
740
ADDRESS:677 SHAWNEE LANETELEPHONE:
(408) 677-3635
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 6DATE:
08/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Ann Marie Zarraga - AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 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 08/09/2024 at 1:10 p.m. Licensing Program Analysts (LPAs) Maria (Mita) Partoza, Marcela Yanez and Marcella Tarin arrived and conducted an unannounced required 1 year inspection visit. LPA was greeted by 3 staff and the administrator (ADM) Ann Marie Zarraga. LPAs stated the purpose of the visit to ADM.

The facility is a Residential Care Facility (RCFE) licensed to serve 60 years and over and approved for 6 ambulatory only. 6 of 6 residents are were present at the time of inspection and are developmentally disabled.

At 1:10 p.m. LPA toured the facility inside and outside with ADM, including but not limited to the kitchen, bathroom, dining room, living room, residents rooms, backyard, garage and walkways. The temperature inside the home was at 78 degrees F.

LPAs observed a sign posted on the front entry way that states "No Smoking, Oxygen in Use."

LPAs with staff (S1) inspected 4 of 4 resident bedrooms. 1 of 4 bedroom is a staff room and 3 of 4 is shared bedroom. LPAs observed 2 bathrooms one on the hallway, and inside the bedroom # (BT1, BT2) LPA observed 3 of 3 resident bedrooms to be organized, sanitary and free from any debris and has sufficient storage for residents' personal belongings. 1 of 3 resident bedroom has a sign posted "no smoking, oxygen in use." 1 of 6 resident uses oxygen as needed and as ordered.

LPAs observed that the facility has smoke and carbon monoxide alarm that are in good working condition. LPAs observed hallways, walkways are free from obstruction. LPAs observed the backyard area to be free from debris and is well maintained. LPAs observed a shed in the backyard that stores walkers, facility equipment used by residents in care. The shed has no lock.



page 1 of 2 see LIC 809C
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2024
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: SERENITAS CARE, LLC
FACILITY NUMBER: 435202795
VISIT DATE: 08/09/2024
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
26
27
28
29
30
31
32
LPAs observed auditory alarm on the front door. LPAs observed sharps and knives were locked and inaccessible to residents, toxic were observed to be properly stored in locked cabinets. LPAs observe 2 days of perishable food and 7 days non-perishable food.

LPAs observed Fire Extinguisher was last serviced on 08/02/2023. LPAs observed refrigerator temperature at 40 degree F, freezer at 0 degree F. LPAs with S1 inspected the garage and observed laundry machine and dryer are in good working. LPAs observe an exit door from the garage that is free from obstruction.

LPAs reviewed resident's records, and observed that records are complete and up to date including Centrally Stored Medication and Destruction Record (CSMDR). Medications are labeled and recorded on the CSMDR. LPAs observed First aid Kit to be complete and easily accessible to staff. LPAs reviewed staff record and observed that records are complete and up to date. Certificates for 1st aid was current, annual continuing education training was not documented. The fire and earthquake drill training was last administered in June 29, 2024 and July 5, 2024 respectively.

LPAs discussed with ADM the importance of documenting training administered to staff, food safety, thermostat in the freezer and refrigerator to ensure proper temperature is maintained and maintenance of the facility bathroom and screen door by the dining room.

Deficiency is cited during today's visit based on California Code of Regulations (CCR) Title 22. See LIC 809D. An exit interview was conducted with ADM Ann Marie Zarraga. A copy of the report and appeals rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 08/09/2024 04:07 PM - It Cannot Be Edited


Created By: Maria Partoza On 08/09/2024 at 03:34 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SERENITAS CARE, LLC
FACILITY NUMBER: 435202795

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
8741(c)(6)
87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive ... annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (6) ...maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2). For on-the-job training, documentation ... This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited 2 of 2 staff record that was reviewed did not maintain documentation of annual training required on based on Health and Safety Code sections 1569.625 and 1569.69(6) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
1
2
3
4
Administrator stated the training will be adminstered to staff and proof of trainingwill be submitted to LPA by the POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Romeo Manzano
LICENSING EVALUATOR NAME:Maria Partoza
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3