Serenity Home Care

Type of visit: Required - 1 Year

On 08/25/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct an annual visit. LPA was greeted by staff member (SM) Ferdinand Estroba and explained the purpose of the visit. LPA was met by SM Lillibeth Sarmiento and asked that SM Sarmiento call the Facility Designated Administrator at this time to inform them that CCL was present. There were 2 other staff members present at the time of this visit, Alona Bastida and Noel Sarmiento. This facility is licensed to serve 6 residents who are 60 and older and can be deemed non-ambulatory. This facility holds a hospice waiver for 6 and has a dementia program on file. Current Census was 6. LPA reviewed 6 resident files. All resident files are current and up to date. LPA reviewed 4 staff files. All staff files are current and up to date. A tour of this facility was conducted. The Administrator has an expired certificate but has renewed their certificate prior to expiration date and is awaiting for a new certificate from the department. Fire extinguisher located by the garage door appeared to have been annually inspected by Jorgenson Co on 05/22/2023. The kitchen area was toured. LPA Pascua observed a sufficient seven days of non-perishable as well as two days worth of perishable food supplies in the main kitchen. Additional perishable supplies were identified in an additional refrigerator located in the garage. Knives and additional cleaning supplies were locked and made inaccessible to the residents at this time. LPA Pascua observed a locked centralized stored medication cabinet located in the dining room. Along with Administrator, the LPA observed, reviewed, and compared resident medication with the medication dispensing logs. First Aid Kit was present and contained all of the required components. Common areas were toured. Living room, dining area and all other areas intended for resident use were in compliance and good repair. A tour of the garage was conducted. Additional storage for supplies were stored in cabinets. A washer and dryer were also identified in the garage. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time. A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees. Grab bars were present and in good repair. A tour of the resident bedrooms was conducted. Resident furniture was observed to be sufficient to meet the resident needs at this time. A tour of the staff bedroom was also conducted. A linen closet was located in the hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time. Additional incontinence supplies were also identified. The exterior of the physical plant was in good repair with no hazards present. Perimeter fence was observed to be stable and gates were in good repair. The following forms and documents were requested to be updated and submitted into CCL. -LIC308 -LIC 400 -LIC 500 -LIC 610 No deficiencies were observed or cited during this annual visit. An exit interview was conducted and a copy of this report was given to Facility Designated Administrator.the state’s words, verbatim · CDSS document, Aug 25, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Arielle Pascua arrived at this facility on 08/04/2022 to conduct an unannounced annual visit. LPA Pascua met with Facility Designated Maria Angelica Souxouay and stated the purpose for today's visit. This facility holds a hospice waiver for 6 and has a dementia program on file. Census was currently 6. A tour of this facility was conducted. Administrator holds a current certificate and expires on, 04/29/2023. The facility has a main entrance COVID screening point. Fire extinguisher located by the garage door appeared to have been annually inspected on 04/16/2022. The kitchen area was toured. LPA Pascua observed a sufficient seven days of non-perishable as well as two days worth of perishable food supplies in the main kitchen. Additional perishable supplies were identified in an additional refrigerator located in the garage. Knives and additional cleaning supplies were locked and made inaccessible to the residents at this time. LPA Pascua observed a locked centralized stored medication cabinet located in the dining room. Along with Administrator, the LPA observed, reviewed, and compared resident medication with the medication dispensing logs. First Aid Kit was present and contained all of the required components. Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time. A tour of the garage was conducted. Additional storage for supplies were stored in cabinets. A washer and dryer were also identified in the garage. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time. A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees. Grab bars were present and in good repair. A tour of the resident bedrooms was conducted. Resident furniture was observed to be sufficient to meet the resident needs at this time. A tour of the staff bedroom was also conducted. A linen closet was located in the hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time. Additional incontinence supplies were also identified. The exterior of the physical plant was in good repair with no hazards present. Perimeter fence was observed to be stable and gates were in good repair. The following forms and documents were requested to be updated and submitted into CCL. -LIC308 -LIC 400 -LIC 500 -LIC 610 No deficiencies were observed or cited during this annual visit. A copy of this report was given to Facility Designated Administrator. Exit interview.the state’s words, verbatim · CDSS document, Aug 4, 2022

Type of visit: Prelicensing

LPA Garcia conducted this announced prelicensing visit. LPA toured with MARIA ANGELICA SOUXOUAY, Administrator. This facility has a fire clearance for six non-ambulatory and six total. Hospice waiver for 6. This facility has two private and two shared resident rooms to the left of the main entrance. There is separate staff living quarters for onsite Administrator. There are 3 ramps available for emergency exits for residents. From the main entrance is an open entry welcome area into the dining room and kitchen. Off the open area is an additional seating area for residents with an attached bathroom. From the kitchen is an additional half bath then entry into the garage with the laundry, dryer, and extra storage. There is a common bathroom accessible to three rooms. There is a private bathroom attached to one of the single occupancy room. Carbon monoxide in hallway and central area. Fire alarms in all resident rooms and central area. Staff and client files are locked in closet area in front centralized office. All cabinets/ closets have keyed locks. The backyard was inspected and there is one gate on south side of the facility. The kitchen was inspected. There is a locked cabinet in kitchen for sharps. There is a locked cabinet that stores the medications. Refrigerated medications will be stored in clear lock box in garage fridge. Controlled medications in lock box in lock cabinet Both front and backyards are well maintained. There are audio alerts on all exits. Each resident has a call system that alerts the caregivers. Component III orientation completed and certificate posted. The Administrator has 5 years of licensing experience in both ARF and RCFE. Administrator Certificate exp. 6/30/21 with Conditional extension. LPA is going to submit this report to the applications specialist for review.the state’s words, verbatim · CDSS document, Aug 20, 2021