Serenity Villa Jja

Type of visit: Required - 1 Year

On 08/16/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Jonathan Espiritu. LPA explained the purpose of today’s visit. The facility is licensed to operate for (6) ambulatory of which (2) may be non-ambulatory elderly adults ages 60 and above. The facility is approved for (2) hospice residents. Currently the home has no residents living in the facility. The facility is a single-story structure located in a residential neighborhood. It consists of the following: (4) residents' rooms, (3) bathrooms, a living area, a dining area, a kitchen, an outside seating area, and a garage used for storage. LPA toured the physical plant. There were no bodies of water on the premises. LPA identified a swimming pool behind a locked gate and not accessible to residents in care. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the resident's personal items was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 105.0 degrees F. A comfortable temperature of 81 degrees F. was maintained in the facility. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Two fire extinguishers were charged. The facility maintains a Medication Administration Record (MAR). (Evaluation Report continues LIC 809-C) During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. LPA observed First Aid Kit was maintained. A working landline phone was operational. The facility maintains a record for monthly fire drills. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 06/09/23 through 06/09/24. An audit of staff #1-#6 (S1-S6) personnel files revealed to be complete. Interviews were conducted with (3) (3) staff. The facility has the current administrator's certification on file for Evelyn Espiritu # 606355740 Expiration 08/21/24. On 04/04/23 regional office received notification letter from administrator Jonathan Espiritu of Serenity Villa that a major water pipe busted in the bathroom #1 and that (6) residents were temporarily relocated. During the annual inspection visit, LPA observed both rooms were repaired and it is now in safe and healthful condition for residents. No deficiencies during this inspection. An exit interview was conducted with Jonathan Espiritu and a copy of the report was providedthe state’s words, verbatim · CDSS document, Aug 16, 2023

Type of visit: Required - 1 Year

On 12/09/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with administrator Jonathan Espiritu and explained the purpose of today’s visit. The facility is licensed to operate for six (6) elderly ambulatory adults of which two (2) may be non-ambulatory. The facility is approved for two (2) hospice residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: (4) resident's rooms, three (3) common bathrooms, a living area, a dining area, a kitchen, and an outside covered patio area. LPA and licensee toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The hot water temperature was tested at 108.1 F. A comfortable temperature of 73 degrees was maintained in the facility. LPA observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. The facility has several fire extinguishers that were charged, smoke detectors, and carbon monoxide was operable.The facility conducted a Fire/Safety Drill on 12/04/22. A working landline telephone remains available. The facility has a current liability insurance effective 06/09/22 - 06/09/23. Evaluation Report Continues on LIC 809-C INFECTION CONTROL: During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed staff wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of the resident's and staff's vaccination records was conducted. The facility has a Mitigation Plan Report on file with CCLD. DEFICIENCIES: Based on interviews, observation, and record reviews, LPA identified staff #3 and staff #5 did not have complete employee files. LPA observed staff #3 and staff #5 did not have current CPR/First Aid Training certificates. LPA observed Medication Administration Records were not maintained in accurate and in order for residents in care. LPA identified resident #3 (R3) did not have physicians report on file. Based on interviews, observation, and record reviews the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8, Deficiencies are issued and an exit interview is conducted with Jonathan Espiritu. A copy of this report, appeal rights, and civil penalty were provided.the state’s words, verbatim · CDSS document, Dec 9, 2022

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Ana Soto conducted an announced Pre-Licensing visit to this facility and was met with Jonathan Espiritu, Administrator. LPA also observed 3 care givers on duty at the time of the visit. The applicant is a corporation Jonathan Espiritu is the President/CEO of the corporation and designated administrator for the facility. This is a change of ownership application. The facility is currently operating as Serenity Guest Home IV #198204856 to Serenity Villa, INC. There are 5 residents at the facility. LPA Soto is conducting component 111 and Pre-licensing. An application was submitted to Community Care Licensing Department (CCLD) on 01/22/2021 for an initial license for Residential Care For Elderly 60 years and above. The requested capacity is for (6) Residents,(0) ambulatory and (5) non-ambulatory and (1) bedridden. Structure: The facility is a one story beige stucco facility. It contains a front patio with a pergola and 2 tables and 4 chairs, 4 bedrooms and 2 1/2 bathrooms, back yard with garden and pool. Covered back patio, and 3 car attached garage. Signal System: Signal system in facility. Bedroom Residents: There shall be no more than two clients per bedrooms. bedrooms are designated resident bedrooms properly equipped with regulation guidelines of two beds, two chairs, two night stands, two lamps and overhead lighting. Presently, bedroom #1 & 3 are shared bedrooms and bedrooms #2 & #4 are private rooms. Bedroom Staff: No bedrooms will be used for awake staff. Bathrooms: 2 1/2 bathroom, 1/2 bathroom located next to kitchen. 2 full bathrooms, 1st bathroom is located in Bedroom #1 and the 2nd located in the hallway between rooms #2 -#4. The 2 full bathrooms have working toilets and wash basin, a walk-in shower with folding bench, grab bars, and mats. 1/2 bathroom has a working toilet and wash basin.Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen is stored in the hallway closet. Emergency Phone Numbers, Exit Plan, & Menu: Emergency numbers and menu are posted and readily available for review: menu on the kitchen refrigerator and emergency numbers posted on the hallway wall in front of the front entrance. Facility has a land line telephone located in the office space next to the dining room. 3 Fire extinguishers, 1 in the kitchen area which is labeled and 2nd next to the front entrance also labeled, and 3rd in the garage, they are tagged with current annual checks. Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in locked storage drawers in the kitchen cabinets. Adequate food supply is stored in kitchen and garage and consists of the following: 2 day perishables, and 7 week non-perishables. Smoke Detectors: There are 7 currently being hard wired smoke detectors. Carbon monoxide detector near room #1. Appliances: Stove burners, oven, microwave, freezers and washers/dryers are in working condition. The residence is equipped with central heat and air conditioning. There is 1 thermostat's for the facility to regulate the temperature for all residents. Toxins: Cleaning supplies, and toxins are stored in the garage. Water Temperature: Water was tested in the 1/2 bathroom it's within 105-120 degrees Fahrenheit range 109 degrees fahrenheit. Medication, First-Aid Kit & Book: Designated area for centrally stored medication is located the cabinet in the office space. A first-aid kit has been inspected which has at least the following: thermometer, tweezers ,scissors, antiseptic, bandages, gauze and current first aid manual, which stored on top of cabinet in the office space , available for staff use but inaccessible to residents. Residents & Staff Files: Designated area for files are located in the cabinet in the office space. Pools/Jacuzzi & Pets: There is a pool and it has a gate with lock, it's inaccessible to residents. There is one dog on these premises. Common areas: Toured common areas including dining room and living room. The dining room has a sliding glass exit door, which exits to the backyard with operational alarm. Adequate furniture and seating accommodations for the requested capacity. LPA observed mid-size screen TV in the living room. Fire Clearance: Fire clearance does indicate delayed egress and/or locked perimeter. Component III was conducted at the time of the visit. There are no corrections to be made. Due to technical difficulties, reports were emailed to Administrator. An exit interview was conducted and a copy of this report has been furnished to the applicant via email for signature. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.the state’s words, verbatim · CDSS document, Sep 3, 2021