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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209023
Report Date: 09/22/2021
Date Signed: 09/22/2021 01:46:45 PM

Document Has Been Signed on 09/22/2021 01:46 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:SERENITY SENIOR CAREFACILITY NUMBER:
547209023
ADMINISTRATOR:ESQUIVEL, BRIANNAFACILITY TYPE:
740
ADDRESS:164 EAST YATESTELEPHONE:
(559) 719-7510
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 6CENSUS: 5DATE:
09/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Brianna EsquivelTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) M. Medina conducted an unannounced an Inspection Control Infection. LPA met with Licensee, Brianna Esquivel and stated purpose of the visit. LPA completed the COVID contact questionnaire prior to entrance into the facility.

LPA observed a central entry point with a supply of hand sanitizer and a sign in policy that includes documented routine symptom screening for resident's, staff and visitors.

Mitigation plan was submitted and approved by Department on 3/25/2021. Procedures described in the plan and observed by LPA include: Daily symptoms screenings (for staff, persons in care and visitors), visitation policy, quarantine/isolation procedures, surveillance testing, infection control plan and identification of Brianna Esquivel as the Infection Control Lead, emergency staffing, PPE use, infection control training and procedures, documentation, postings and communication.

LPA toured the facility inside and out. Required postings of signs to include hand washing, coughing etiquette and physical distancing were observed in the facility. Staff were observed wearing face coverings. Facility has designated visitation areas. LPA observed a 30 day supply of PPE and resident medications. Fire extinguisher present with a service date of 8/03/2021. Carbon monoxide and smoke detectors present and observed to be operational during today's inspection.

Licensee to submit the following documents to Fresno CCL no later than 10/01/21: LIC 500, LIC 610, LIC 9020, Administrator certificate, first aid card.

Through LPA observations, documentation review and interview with Licensee, the required infection control practices are found to be in compliance. No deficiencies cited during today’s inspection.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2021
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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