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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486802085
Report Date: 04/18/2024
Date Signed: 04/18/2024 05:22:01 PM

Document Has Been Signed on 04/18/2024 05:22 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
Lookup Error,
, CA
FACILITY NAME:BUCK SERENITY HOMESFACILITY NUMBER:
486802085
ADMINISTRATOR/
DIRECTOR:
CASTRO, GIDEONFACILITY TYPE:
740
ADDRESS:691 BUCK AVENUETELEPHONE:
(707) 449-8394
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 6CENSUS: 4DATE:
04/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Gideon Castro, Administrator and Elena Castro, caregiver TIME VISIT/
INSPECTION COMPLETED:
05:25 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual.
LPA met with Gideon Castro, Administrator and Elena Castro, caregiver, and explained purpose of inspection. Also present were caregivers, Teodorico Santos and Gina Taganahan. LPA observed (1) resident to be visiting with a family member in the common area and (3) residents to be resting in their rooms. The facility is located away from the main street and is up on a hill with a view. There are no neighbors in close proximity. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (3). Currently, there is (1) resident under hospice care.

toured the interior and exterior of the facility including the common areas, (4) private resident bedrooms (6) private resident bedrooms, (4) resident bathrooms, kitchen, laundry area and (2) staff rooms on the second floor. LPA observed the facility to be clean, in good repair and odor-free. LPA observed the bathrooms to have the necessary grab bars, non-skid flooring, paper towels and hand-washing posters. There is sufficient 2+day perishable, including fresh produce, and 7+day non-perishable supply of food. Sharps, medications and toxins are locked in/near the kitchen. The inside temperature measured 76*F and the hot water measured 105*F in resident bathroom. The smoke/monoxide alarms are working and quarterly drills are conducted. There are sufficient linens/towels/blankets and paper supplies, including PPE. Each resident room has an exit to the backyard and there is main parking gate near the front entrance. There are no pools/ponds.

LPA reviewed (2) of (4) resident files and found them to be organized and contain current physician's reports and appraisals. Medications were reviewed for (1) resident- orders matched medications administered and MAR documentation is current. LPA reviewed (5) of (9) staff files and found them to be complete and contain current training documentation, including for First Aid/CPR. RCFE Administrator Certificate #6016577740- exp 5/19/24- renewal has been initiated. All staff is cleared and associated. LPA requested an updated copy of the LIC308, LIC500 by 4/25/24. Copy of current liability insurance was obtained. There are no citations issued. Exit interview. Copy of report provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
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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