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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803720
Report Date: 07/14/2022
Date Signed: 07/14/2022 10:47:59 AM

Document Has Been Signed on 07/14/2022 10:47 AM - 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 VILLA IIFACILITY NUMBER:
496803720
ADMINISTRATOR:REZNIK, AIDAFACILITY TYPE:
740
ADDRESS:184 BOAS DRTELEPHONE:
(415) 609-3827
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 12CENSUS: 11DATE:
07/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Licensee, German SinitsynTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 07/14/2022 to conduct a case management inspection regarding an unusual incident report received by Community Care Licensing on 06/29/2022. Incident report details a resident AWOL on 06/28/2022. LPA was greeted by staff. Licensee, German Sinitsyn arrived later.

During inspection LPA conducted interviews, reviewed records, and toured the facility. LPA noted the door through which the resident exited the facility per staff. The door had a working alarm system installed and an alarmed mat which sounds if stepped on. Per staff resident exited through this door and walked to next door neighbor's house. Resident was found and returned to the facility by the police. Calling the police is standard facility procedures. Resident was found within 30 minutes. Licensee stated that about 10 minutes went by before caregivers realized that resident had left the facility. Facility monitors residents for changes in condition and makes adjustments as needed to resident service plans.

Exit interview conducted with licensee and a a copy of this report printed for the facility.

No deficiencies cited during today's inspection.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2022
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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