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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486802085
Report Date: 03/05/2026
Date Signed: 03/05/2026 03:26:15 PM

Document Has Been Signed on 03/05/2026 03:26 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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: 5DATE:
03/05/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:11 AM
MET WITH:Gideon Castro-Adminsitrator TIME VISIT/
INSPECTION COMPLETED:
03:40 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
Licensing Program Analyst (LPA) Contreras arrived unannounced to conduct a required annual inspection and was greeted by administrator(admin) Gideon Castro. Facility is an Adult Residential Care for the Elderly licensed for a capacity of 6 residents. There are currently 5 residents in care. Facility is a two story facility, residents reside in first floor and staff rooms are located in second floor of facility.

LPA toured the building and grounds which was found to be at a comfortable temperature. LPA observed at least a 2- day supply of perishable and 7- day supply of non-perishable food. Expiration dates were not noted in some food items in refrigerator (Technical Violation given). Resident bathroom had required bath mat and grab bar. Bathroom found with paper towels and toilet paper. Dryer and washer found operational. Toxins found in two resident bathrooms unlocked under bathroom sink including chemicals found unsecured in bathrooms accessible for residents(Deficiency cited, see 809D). Water temperature in sink accessible to residents in care measured within the allowable range of 105 to 120 degrees F. Resident bedroom observed to be equipped with lighting, night stand, and chest of drawer. LPA toured the outside backyard of facility and observed emergency exits free from obstruction. Noticeable spider webs and collected dust observed in resident window sills (Technical Violation given). Five out of five resident rooms did not have door signal system turned on in door that leads to outdoor perimeter of facility (Deficiency cited, see 809D). Fire extinguishers were last inspected 4/15/2025. Smoke/Carbon Monoxide detectors located throughout the facility are tested through Fire Marshall. Disaster drills conducted quarterly.

LPA conducted file review for 5 out of 5 residents. LIC613 Personal Rights signature missing from one (R1) resident file (Technical Advisory given).

Continued onto 809C.....
NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Ethel Contreras
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2026
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 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BUCK SERENITY HOMES
FACILITY NUMBER: 486802085
VISIT DATE: 03/05/2026
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
continued from 809...

LPA conducted file review for 3 staff. One staff (S1) missing LIC501 Job Application (Technical Advisory given) .

LPA conducted medication spot check. Centrally stored log up was observed to not be complete with 9 medications not listed in Centrally Stored Medication Log for R2 (Deficiency cited, see 809D).

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
Liability Insurance

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with administrator.

NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Ethel Contreras
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2026
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/05/2026 03:26 PM - It Cannot Be Edited


Created By: Ethel Contreras On 03/05/2026 at 02:52 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: 03/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
87465(6)(h)

87465 Incidental Medical and Dental Care(h) The following requirements shall apply to medications which are centrally stored:The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [LPA and admin record review and observation, the licensee did not comply with the section cited above in that Centrally Stored Medication Log was not complete for S2 requiring medication administration which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2026
Plan of Correction
1
2
3
4
Facility to submit to CCL plan to complete centrally stored medication logs(CSML) for resident by plan of correction due date 3/06/2026. Completed CSML to be submitted to CCL no later than 3/09/2026
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.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Ethel Contreras
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 03/05/2026 03:26 PM - It Cannot Be Edited


Created By: Ethel Contreras On 03/05/2026 at 02:59 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: 03/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and admin observation, the licensee did not comply with the section cited above in Toxins found in two resident bathrooms unlocked under bathroom sink including chemicals found unsecured in bathrooms accessible for residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2026
Plan of Correction
1
2
3
4
Licensee to submit LIC9099 self certifying that all toxins have been removed with pictures OR add lock to facility sinks with pictures to CCL by plan of correction due date 3/06/2026
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.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Ethel Contreras
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 03/05/2026 03:26 PM - It Cannot Be Edited


Created By: Ethel Contreras On 03/05/2026 at 02:59 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: 03/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(i)(1)(A)
Maintenance and Operation
(i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [LPA and admin observation licensee did not comply with the section cited above in 5 out of 5 resident room did not have door signal system on which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2026
Plan of Correction
1
2
3
4
LIcensee to submit plan of how facility will ensure that all signal system alarms for all resident bedrooms are on at all times to CCL by plan of correction due date 3/12/2026
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.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Ethel Contreras
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2026


LIC809 (FAS) - (06/04)
Page: 6 of 6