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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803610
Report Date: 01/09/2024
Date Signed: 01/09/2024 12:46:20 PM

Document Has Been Signed on 01/09/2024 12:46 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:SERENITY VILLAFACILITY NUMBER:
496803610
ADMINISTRATOR:REZNIK, AIDAFACILITY TYPE:
740
ADDRESS:477 PETALUMA AVENUETELEPHONE:
(415) 609-3827
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY: 21CENSUS: 16DATE:
01/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:39 AM
MET WITH:German Sinitsyn (Licensee)TIME COMPLETED:
01:01 PM
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Licensing Program Analyst, (LPA) Cuadra, arrived unannounced to conduct an Annual Required Inspection and met with Erica Campos (Lead Staff). German Sinitsyn (Licensee) arrived later. One resident is receiving hospice services. Required postings were observed. Activity Calendars and Weekly Menus posted.

LPA/Staff initiated a tour of the facility at 9:00 am and made the following observations: Facility was a comfortable temperature, well lit and passageways were free from obstructions. Residents were engaged in exercising activities during inspection. Resident rooms were furnished per regulation. Water temperature in bathrooms used by residents measured at 113.2, 105.1 and 106.2 degrees F which are all within allowable range of 105 to 120 degrees F. Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. Closets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable and one week of non-perishable foods. Containers were labeled and covered per regulation. Medications were centrally stored and locked in the medication room.

Fire extinguishers were last inspected December, 2023. Facility has a centralized smoke alarm and sprinkler system that is maintained by a vendor. The most recent inspection was conducted January 2024. Carbon monoxide detector was tested and operational. Exit doors have auditory alerts that were functional at time of visit. Each resident has a pendant to alert staff if the resident needs assistance. Last Disaster Drill was conducted on 10/11/23. Facility provides transportation to residents to their medical appointments.
Continues on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2024
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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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: SERENITY VILLA
FACILITY NUMBER: 496803610
VISIT DATE: 01/09/2024
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Continued from LIC809...

File review was initiated at 10:00 am. 5 staff files and 10 resident files were reviewed. Staff have required First Aid and CPR certificates and annual continuation training hours were complete. 10 out of 10 residents' medical assessments and care Plans were updated/signed by a responsible party as required per regulation. Administrator Certificate for Licensee/Administrator Aida Reznik, 6034483740, expires on 4/11/25.

Medications and medication records were reviewed. A spot check of Medication and medication records was also conducted at 11:00am LPA/Licensee found medication count discrepancies in at least 4 different medications (Acetaminophen 500mg, Hydrocodone 5-325mg, Docusate SOD 250mg and Amlodipine 2.5mg) checked for resident (R6 & R10). Licensee stated that they have not had a pharmacy audit at least twice a year, LPA will issue a technical violation.

Licensee/Administrator to submit updates of the following documents by 1/19/24: Designation of Administrative Resposibility (LIC308), Personnel Report (LIC500) & Liability Insurance Certificate.

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

Exit interview was conducted with Licensee and a copy of this report was provided.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/09/2024 12:46 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 01/09/2024 at 12:18 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: SERENITY VILLA
FACILITY NUMBER: 496803610

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA/Licensee's observation, spot check, records review and interview, the licensee did not comply with the section cited above in 4 out of 7 medications reviewed for residents in care were not given according to the physician's orders, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2024
Plan of Correction
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Licensee agrees to contact a pharmacy to come and review their medication management. All staff will receive training after audit is complete to ensure compliance with regulation. Licensee will submit proof of pharmacy audit by POC due date to clear the deficiency.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024


LIC809 (FAS) - (06/04)
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