Serenity Garden Escalon

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) M. Flores arrived at the facility unannounced to conduct a required annual visit. LPA explained the purpose of the visit and was granted entry by Administrator, Phoeun Marez. The residence was set at 72 degrees F temperature and free of passageway obstructions inside and outside. LPAs observed six bedrooms in the residence. Residents' rooms were toured and inspected. Rooms were found to be clean, and furnishing was in good condition. Kitchen toured, supply of food observed, and food stored properly for perishable and nonperishable. Medication and knives are locked in the kitchen area. Cleaning supplies are locked and stored in the garage. Smoke detectors and carbon monoxide were checked and operating. Fire extinguishers was serviced on 3/16/2023. Last drill completed on 09/06/23. There was outdoor seating for the residents. Outdoor area was clean and free of obstruction. Deficiencies are being cited based on LPA observation in accordance with the California Code of Regulations, Title 22, see LIC809D. During record review it was found that S1 was not clear to work in the facility. During the visit a file review was conducted for residents and staff files. An exit interview was conducted, and a copy of this report was provided to AD1 whose signature confirms receipt. LPA requested the following updated forms faxed to CCLD by 11/15/23: Designation of Facility Responsibility (LIC308), Administrative Organization (LIC309), Personnel Report (LIC 500), Proof of current Liability Coverage.the state’s words, verbatim · CDSS document, Nov 8, 2023

The state marks this report as 7 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Lady Cabrera arrived unannounced for an Annual Required Inspection. LPA contacted Administrator Gina Flores and reported she was unavailable and designated Staff Phoeun Marez to meet with LPA. LPA stated the purpose of the visit. A tour of the facility was conducted. COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point. Facility appeared clean with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Bathrooms have trashcans with lid. Hand washing posters were observed by the bathrooms. Bedrooms were checked. The exterior tour was conducted. LPA checked residents’ medications and observed a 30-day supply. Food supply was checked and there appeared to be an adequate supply. Cleaning and PPE supplies were checked. Staff records were reviewed for good health and infection control training. Facility staff on duty were not wearing face masks. LPA reminded staff to wear a face mask at the facility. Residents wear masks when away from the community. Resident’s files have updated emergency contact information. Deficiency cited on LIC809D. Exit interview conducted and Appeal Rights were provided. Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below: Residential Care Facility for the Elderly (RCFE): · LIC 308 Designation of Facility Responsibility · -as applicable: LIC 309 Administrative Organization · -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources · -as applicable: LIC 402 Surety Bond · LIC 500 Personnel Report · LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly · LIC 9020 Register of Facility Clients/Residents · Copy of current Liability Insurance · Copy of current Administrator Certificate · Alternate contact information including name, telephone number, & email address. Please submit the above forms/information to Fresno CCL by: 12/17/2022 As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed.the state’s words, verbatim · CDSS document, Dec 7, 2022

The state marks this report as 6 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Prelicensing

On 11/29/2021 Licensing Program Analyst (LPA) M. Garza arrived at the facility to complete a Pre-Licensing visit with Licensee, Gina Flores. LPA met with Gina and was permitted entry into the facility. COVID-19 screeening measures in place. A complete tour, inside and out, was conducted with Licensee and LPA.. Facility was observed at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. Common areas were properly furnished and well-lit throughout. The tour started in the bedrooms. Residents bedrooms were observed to be adequately furnished with bed, dressers, night stands and adequate lightning. Bathrooms were properly equipped with non-skid mats and securely fastened grab bars. Hot water was tested in two sinks at degrees 108 and 112 F. An adequate supply of linens and personal hygiene supplies were observed. There are no bodies of water outside. Fire extinguisher was observed with a service date of 10/20/2021. Carbon monoxide and smoke detectors were tested and observed to be operational. Cleaning supplies and chemicals were observed locked in the laundry area, under sinks and in the locked garage. First Aid Kit was checked and observed to have the required supplies. The tour concluded in the kitchen. Medications will be kept in a locked closet in the kitchen. Dining utensils were observed. Emergency exit plan, phone numbers, and required postings were observed. A working telephone was present. Pre-Licensing is complete and this facility has no deficiencies. Comp III was completed. Exit Interview was conducted with Licensee. A copy of this report will be emailed to: serenitygardenhomes@gmail.com due to COVID precautionary measures being taken. A delivered and read receipt serves as confirmation.the state’s words, verbatim · CDSS document, Nov 29, 2021

Type of visit: Office

COMP II by CAB successfully completed. Facility Type: RCFE Application Type: Initial Capacity: 6 Census (if any clients in care): 0 COMP II Participants: Gina Flores, Administrator Interview Method: Telephone interview On November 10, 2021 at 1:00 PM, Administrator participated in COMP II via telephone with Analyst, Celia Phomphachanh from CAB. Identification of the Licensee was verified by providing California Driver License number verbally. During COMP II, Applicant confirmed the understanding of Title 22 and Health and Safety Codes. Component II was successfully completed. Administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB Analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility Operation: License type, client/resident populations, and program 2. Staff Qualifications and responsibilities 3. Applicant and Administrator Qualifications 4. Program Policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical Plant and Food Service 7. Application Document Review and Technical Assistance: Criminal Record Clearance, Health Screening, Fire Clearance, First Aid/CPR Certificate, Administrator Certificate, Financial Verification, Pre-licensing Inspection, Compliance History and Control of property. Interviewed concluded with Administrator. LIC 809 will be sent via email PDF to Administrator.the state’s words, verbatim · CDSS document, Nov 10, 2021