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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803720
Report Date: 10/07/2021
Date Signed: 10/07/2021 03:38:28 PM

Document Has Been Signed on 10/07/2021 03:38 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:SERENITY VILLA IIFACILITY NUMBER:
496803720
ADMINISTRATOR:REZNIK, AIDAFACILITY TYPE:
740
ADDRESS:184 BOAS DRTELEPHONE:
(415) 609-3827
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 12CENSUS: 9DATE:
10/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Staff, Adriana GuerrerroTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA), Erik Gonzalez Campos arrived unannounced to conduct a Required - 1 Year inspection at approximately 2:15 PM. LPA was greeted by staff, Adriana Guerrero. Administrator was not present. LPA called administrator to inform them of the inspection, administrator confirmed they approved of LPA conducting inspection with staff. The inspection is focused on the Infection Control procedures and practices of this facility. There are currently 9 residents in care.

Upon entry LPA was screened for COVID symptoms and asked to sign in by staff. At primary entrance LPA observed temperature logs and visitor sign-in sheet. LPA conducted walk through of the facility with staff. LPA found the facility to be clean, free of obstructions, and a comfortable temperature. Mitigation plan has been submitted and approved by Community Care Licensing (CCL).

LPA and staff discussed isolation procedures in case of infection. Three bedrooms are currently shared but the facility has a procedure in place. Staff explained that one bed is empty which allows them to move around residents if needed. Staff showed LPA the necessary Personal Protective Equipment (PPE) to support a resident in isolation. Facility has a 100 percent vaccination rate for staff and residents and does not conduct surveillance testing. LPA observed hand sanitizer and hand washing signs in bathrooms. Exit alarms were observed to be working properly. Visitation areas are setup outside and facility is allowing communal dining.

Residents' emergency contact information has been updated and staff confirmed they are familiar with 911 procedures and protocols. Toxins are secured and inaccessible in a locked hallway closet and laundry room cabinet. A 30 day supply of medications are stored in a medication room, making them inaccessible to residents. LPA requested copy of updated liability insurance.


No deficiencies cited during todays inspection.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2021
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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