Serenity Villa Assisted Living

Type of visit: Case Management - Other

At 12:30 p.m., Licensing Program Analyst (LPA) Evelin Rios conducted a Case Management Visit - Other to confirm the closure of this facility. LPA contacted the Licensee/Administrator Francisco Martinez via email and was informed the facility was closed, with no residents and no intention of renewing the License. LPA confirmed that there were no residents residing in the facility and that operation had ceased. Prior to the closure the facility did not have any residents. Licensee will mail license to the Regional Office. The Licensee is reminded that they may not admit or retain any residents at the home who require care and supervision. LPA will e-mail the closure survey. Exit Interview conducted and copy of this report will be emailed for signature.the state’s words, verbatim · CDSS document, Dec 3, 2025

Type of visit: Case Management - Deficiencies

On 03/11/2025 in conjunction to complaint control #31-AS-20250124110820, Licensing Program Analyst (LPA) Evelin Rios conducted a Case Management Deficiencies Visit. LPA met with the administrator and explained the reason for the visit. On 01/28/2025 at 10:24 a.m., LPA conducted a physical plant tour to ensure the health and safety of the residents in care. During this tour, at approximately 10:27 a.m., LPA interviewed resident #1 (R1). At approximately 10:30 a.m., LPA conducted an interview with the administrator. At 11:00 a.m., LPA reviewed the facility's Licensing Information System (LIC) facility profile, Guardian Background Check System, employee roster, and fire inspection with facility sketch. LPA's review of the approved fire inspection (LIC 850) from 10/12/17 and facility sketch revealed the facility has a capacity of six (6) with five (5) non ambulatory residents and one (1) bedridden resident. Facility sketch revealed bedroom labeled #1 is approved as a shared room for one (1) bedridden resident and one (1) non ambulatory resident, bedroom labeled #2 is approved for two (2) non ambulatory residents and bedroom labeled #3 and #4 are cleared for one non ambulatory resident each. During the physical plant tour LPA observed the garage had been converted into living quarters for the licensee and bedrooms labeled #2 and #3 are each currently occupied by licensee's family members. The Administrator stated that they intend to comply with regulations and will be submitting the required documentation. Deficiency cited refer to (LIC809-D). Exit interview conducted. Appeals rights provided. Copy of report provided.the state’s words, verbatim · CDSS document, Mar 11, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(a)(7)(A) · Plan of correction due date: Apr 11, 2025

(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility...The plan and related materials shall contain the following: (7) Sketches, showing dimensions, of the following (A) Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended and a designation of the rooms...This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above in not providing CCLD with an updated facility sketch and designation of the rooms which is a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 11, 2025

Plan of correction: Licensee agreed to provide a copy of the approved permit for the garage conversion and submit an updated facility sketch with current designation of the rooms by POC due date.

Allegation investigated: Staff do not provide adequate food service

On 01/28/25, Licensing Program Analyst (LPA) Evelin Rios conducted an initial unannounced complaint visit to address a specific allegation. After further review it was determined that the allegation addressed on 01/28/25 visit was not applicable to California Code of Regulations, Title 22, Division 6, Chapter 8. On 03/11/25 LPA Rios amended the initial report to address the appropriate allegation mentioned above and deliver a determination. LPA arrived at the facility at 10:15 a.m. and was greeted by the administrator Francisco Martinez. LPA explained the purpose of the visit. An entrance interview was conducted. On 01/28/2025 at 10:24 a.m., LPA conducted a physical plant tour to ensure the health and safety of the residents in care. During this tour, at approximately 10:27 a.m., LPA interviewed resident #1 (R1). At approximately 10:30 a.m., LPA conducted an interview with the administrator. At 11:00 a.m., LPA reviewed the facility's Licensing Information System (LIC) facility profile, Guardian Background Check System, employee roster, and facility sketch. (Cont. to LIC9099-C) Unsubstantiated (Continued from LIC9099) Allegation: Staff do not provide adequate food service. The allegation was reported as "facility food was not good." To investigate the allegation, LPA Rios interviewed resident #1 (R1) and the administrator. The administrator explained that meals are prepared by him or one other staff, and emphasized that they do not prepare meals they wouldn't eat themselves. Additionally, the administrator has not received complaints about the food provided. LPA's interview with R1 revealed that they eat the meals provided, have not refused food, and have not requested substitutes. R1 also mentioned that they like to have the same meal for breakfast and communicate this request to the administrator without issues. LPA observed a sufficient supply of two days perishable food and seven days non-perishable food, all properly stored. Based on interviews and LPA's observations, the allegation is deemed Unsubstantiated at this time. Exit Interview Conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 28, 2025 · control 31-AS-20250124110820

Type of visit: Required - 1 Year

On 11/22/2024 at 12:10 p.m., Licensing Program Analyst (LPA) Evelin Rios arrived to conduct an unannounced, annual inspection at the facility. Upon arrival, LPA met with staff #1 (S1), who granted access. S1 contacted the licensee, Francisco Martinez. The licensee met LPA shortly after and LPA explained the reason for the visit. The facility is a licensed Residential Care Facility for the Elderly (RCFE), with a capacity of six (6) non-ambulatory residents of which one (1) may be bedridden in bedroom #1. The facility also has a Hospice waiver for two (2) residents. At approximately 12:20 p.m., LPA conducted a tour of the physical plant and the following was observed: Common Areas: These included living room and dining area. The living room was clear of clutter, furnished with couches and recliners to sit the capacity of the facility. The dining room has a table with chairs large enough to seat six (6). A fireplace was observed secured with a screen. Furniture was observed to be in good repair. Hallways, entry and exits were clear of any obstructions. Kitchen: The kitchen was observed to have a refrigerator, stove/oven, dishwasher and microwave. Fixtures and appliances were observed functional. LPA observed a sufficient amount of 2-days perishable and 7 -days non-perishable food in the facility. Knives were observed locked in a kitchen drawer. Centrally stored medication was observed locked in a closet by the kitchen. A fully charged fire extinguisher was observed by the kitchen. LPA observed a fully stocked first aid kit with the emergency and disaster plan. Bedrooms: There are a total of four (4) resident bedrooms. LPA observed each resident room to be properly furnished and have appropriate beddings, linens and sufficient lighting. Exit doors had auditory alarms that were observed functioning. (Continued on LIC809-C) Bathrooms: The facility has two (2) bathrooms one is located in a resident's private bedroom. Bathrooms were properly supplied with hand soap, toilet paper and paper towels. Hot water temperature in the bathrooms were tested at 12:00 p.m. and measured 111.8 degrees Fahrenheit, within regulation. The facility is equipped with a carbon monoxide detector, LPA observed it functioning at 12:24 p.m. The facility is equipped with smoke detectors through out the facility. LPA observed licensee test smoke detectors at approximately 2:08 p.m. and were observed to be functioning. Surrounding Grounds: Backyard space was large enough for outdoor activities. There is a covered patio with outdoor furniture. Laundry Area: The laundry area was observed accessible to residents and leads to bedroom labeled #4 and the staff room. Cleaning supplies and detergents were locked in cabinets in the laundry room. Client/Staff Records: Facility, resident and and staff records were reviewed to insure compliance. At 12:50 p.m. LPA reviewed two (2) of two (2) resident records and two (2) staff records. LPA's review of resident #1 (R1) record revealed a written pre-admission appraisal was not conducted prior to R2 moving in. LPA's review of one (1) of two (2) staff records revealed one (1) staff did not have 1st aid and CPR on file. LPA reviewed resident roster, personnel report, expired liability insurance certificate, infection control plan, emergency and disaster plans and drills. LPA and licensee discussed the fire clearance request made on December 2022 to change the ambulatory status in bedroom #4. Licensee will send LPA an updated facility sketch. LIC200 is still on file for processing the request. LPA will also change current administrator Jerrilyn Martinez to Francisco Martinez. Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were deficiencies observed during the visit refer to (LIC809-D). Exit Interview Conducted. A Copy of the report issued.the state’s words, verbatim · CDSS document, Nov 22, 2024