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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486802085
Report Date: 02/04/2022
Date Signed: 02/04/2022 04:01:59 PM

Document Has Been Signed on 02/04/2022 04:01 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BUCK SERENITY HOMESFACILITY NUMBER:
486802085
ADMINISTRATOR:CASTRO, GIDEONFACILITY TYPE:
740
ADDRESS:691 BUCK AVENUETELEPHONE:
(707) 449-8394
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 6CENSUS: 5DATE:
02/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Licensee, Gideon CastroTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Katrina Walters arrived unannounced to conduct a REQUIRED 1 Year Annual Inspection and was greeted by staff. The Administrator, Gideon Castro arrived later. This visit is focused on infection control. The facility has submitted an infection control plan, which was approved by Community Care Licensing.

The visitor policy was posted on the exterior door. At the entrance there was a sign in book disinfecting wipes and hand sanitizer for visitors.

LPA toured the facility with staff and made the following observations: The facility was clean and comfortable temperature, exits were free from obstructions. The fire extinguisher was last inspected 2/25/21. Smoke detectors and carbon monoxide detectors appeared to be operational. Auditory alarms on all exit doors were on an functional. All residents rooms were furnished per regulation. Signs were also posted throughout the facility to promote social distancing and hand washing. In the event of a COVID outbreak, the facility is able to isolate and quarantine all residents. Facility has at least a 30 day supply of incontinence and Personal Protective Equipment. Facility is disinfected twice daily, and after usage. Facility has a system for documenting the vaccination status of residents, visitors, and staff. All staff and resident's are 100% vaccinated. Per Administrator they have received infection control training from Solano Public Health.

Continued on 809 D
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BUCK SERENITY HOMES
FACILITY NUMBER: 486802085
VISIT DATE: 02/04/2022
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At approximately 2:10 PM, LPA observed wound medication on the side table in resident (R1)'s bedroom. LPA then observed that R1 had a wound that was approximately 5 inches long on their ankle. (picture taken). The wound appeared to be beyond a stage 2. R1 had an appointment with wound clinic. Facility did not document the wound on the resident needs and service appraisal or in an incident report, however per Administrator the wound appeared a month ago.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided to the Administrator, Gideon Castro. Appeal Rights Given.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/04/2022 04:01 PM - It Cannot Be Edited


Created By: Katrina Walters On 02/04/2022 at 03:47 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BUCK SERENITY HOMES
FACILITY NUMBER: 486802085

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87615(a)(1)

87615 (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews and record review, the licensee did not comply with the section cited above. Facility retained R1 who had an unstaged wound. Although the injury is not yet staged, it appears to be more than stage 2. Which poses/posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/11/2022
Plan of Correction
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Licensee to ensure all residents are appropriate for licensed level of care; Licensee to review regulation 87615; Licensee to update R1’s needs and service plan; Licensee to obtain physician’s report in which wound is stage. If Licensee wishes to retain, R1, they will need an exemption.
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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Katrina Walters
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2022


LIC809 (FAS) - (06/04)
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