Serene Care Jacqueline

Type of visit: Case Management - Other

On 5/12/2026 at 4:10pm Licensing Program Analyst (LPA) L. Hall arrived announced to conduct a Case Management visit. LPA met with Roche Castro, Administrator. While LPA L. Hall was conducting a pre-licensing inspection LPA observed the following deficiency: LPA was informed the Administrator has been on a leave of absence for 5 (five) weeks. During record review LPA observed CCLD was notified of that R1 was placed on hospice. The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the appeal rights, LICthe state’s words, verbatim · CDSS document, May 12, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: May 26, 2026

(a) All facilities shall have a qualified and currently certified administrator... The administrator... shall be on the premises a sufficient number of hours... there shall be coverage by a designated substitute. This requirement was not met as evidence by: Based on interview and observation the Licensee did not comply with the section above of having a qualified administrator here for sufficient number of hours, which poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 12, 2026

Plan of correction: Facility is in the process of change of ownership and will have a new administrator. Deficiency will be cleared with new license.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87632(d)(2) · Plan of correction due date: May 19, 2026

(d) If the Department grants a hospice care waiver... which shall include... the following requirements: (2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care... or five working days of admitting a resident already receiving hospice care services. This requirement was not met as evidence by:the state’s words, verbatim · CDSS document, May 12, 2026

Plan of correction: LPA presented COMP III. New administrator understood about reporting new hospice residents. Deficiency cleared during visit.

Allegation investigated: Staff are not allowing resident to return to the facility Staff do not ensure that resident's medication is refilled in a timely manner

On 1/24/2026 at 4:40pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver a complaint finding for the allegations above. LPA met with Annabel Danan, House Manger, and explained the reason for the visit. During the course of the investigation the Department conducted interviews with staff, witnesses, residents, obtained and reviewed records. Allegation: Staff are not allowing resident to return to the facility During the initial interview W1 reported that the facility is not allowing R1 to return to the facility due to nonpayment. W1 stated S2 advised that R1 could Continued on LIC9099C. Substantiated Continued from LIC9099. not return without payment for the time R1 has resided at the facility and a 30-day notice would not be given. W2 stated during interview that R1 was not sick R1 was dropped off with a note and left at the hospital. S3 stated during interview that R1 was taken to the hospital by S2 and S3 for medication. S3 had no further information regarding R1. During interview with S2 on 2/18/2026, S2 stated that R1 was not allowed to return to the facility with a contract from Kaiser. Allegation: Staff do not ensure that resident's medication is refilled in a timely manner During the initial interview W1 was informed on 10/15/2025 that R1 was out of medication. W1 reported R1 had an appointment on 10/23/2025, however, staff did not pick up R1’s medication until 10/29/2025. S1 stated during interview that R1 was out of two medications. Staff tried to contact CCHP (Contra Costa Health Plan) but did not receive a response. During interview S1, S2, and S3 stated R1 did not have any medication and there was an insurance issue. S2 stated R1 was taken to emergency due to not having any medications. LPA also reviewed a copy of the note that was given to R1 that stated R1 did not have any medication for three weeks. Based on interviews which were conducted, record review, and observation the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. A copy of the appeal rights and this report provided.the state’s words, verbatim · CDSS document, Feb 24, 2026 · control 15-AS-20251031101324

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(c) · Plan of correction due date: Mar 3, 2026

(c) The licensee shall, in addition to either serving the required thirty (30)... notify or mail a copy of the notice to the resident's responsible person. This requirement was not met as evidence by: Based on interviews and record review the Licensee did not comply with the section cited above in not letting R1 return to the facility and did not issue an eviction notice, which poses a potential person rights issue to persons in care.the state’s words, verbatim · CDSS document, Feb 24, 2026

Plan of correction: Administrator agreed to review regulation 87224 and submit a self-certification that the facility will abide by the regulation going forward and submit the self-certification to CCLD by the POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a) · Plan of correction due date: Mar 3, 2026

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical... and provide for assistance in obtaining such care... This requirement was not met as evidence by: Based on interviews and record reviews, the Licensee did not comply with the section cited above in helping R1 obtain medication, which poses a potential health issue to person in care.the state’s words, verbatim · CDSS document, Feb 24, 2026

Plan of correction: : Administrator agreed to implement a plan for staff when a resident have not received their medication and submit plan to CCLD by POC date.

Type of visit: Case Management - Other

On 2/4/2026 at 12:50pm, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Annabel Danan, House Manager. Administrator, Isagani Silvestre, arrived at 2:03pm, and LPA explained the purpose of the visit. While LPA L. Hall was conducting a complaint investigation (15-AS-20251031101324) on 2/4/2026. LPA observed Administrator was not present. LPA reviewed prior visits and observed Administrator was not present on 1/15/2026, 11/14/2025, 10/14/2025, 7/1/2025, 5/8/2025, and 4/24/2025. The Administrator should be on premises a sufficient number of hours. The deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, Feb 4, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405 · Plan of correction due date: Feb 11, 2026

(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited above in having the Administrator present a sufficient amount of hours, which poses a potential safety, health, and personal rights, to person in care.the state’s words, verbatim · CDSS document, Feb 4, 2026

Plan of correction: Administrator agreed to review regulation 87405 and submit self-certification that the facility will abide by the regulation going forward to CCLD by POC date.

Allegation investigated: Licensee is retaining a resident with a higher level of care need. Resident sustained a pressure injury due to staff neglect.

On 10/14/2025, at 2:30pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver a complaint finding for the allegations above. LPA met with Annabel Danan, House Manager, and explained the reason for the visit. LPA spoke with Administrator, Isagani Silvestre, via telephone. During the course of the investigation the Department conducted interviews with staff, witnesses, obtained and reviewed documentation. Allegation: Licensee is retaining a resident with a higher level of care need. During the initial interview W1 stated that the facility was retaining a resident Continued on LIC9099C. Substantiated Continued from LIC9099. that required a higher level of care. W1 stated that R1 has prohibited health condition, and the staff were not trained in how to assist R1 with the condition when needed. R1 was admitted to the facility 01/01/2025. The prohibited health condition that R1 has requires the facility to request an exception prior to admission, however, the facility did not submit a request for the exception. R1 was admitted into hospice services on 4/30/2025. R1 expired on 9/4/2025. Allegation: Resident sustained a pressure injury due to staff neglect. During the initial interview W1 stated resident sustained a pressure injury due to staff neglect. W1 stated R1 had a wound on her finger and one on her foot. W1 was unsure if the facility staff was trained how to position R1. During interview on 10/14/2025, both S1 and S2 stated that R1 had a wound on her left heel. S1 stated pillows were placed near bottom of R1's body due to her diagnosis. LPA did not observe any documentation that facility contacted any medical professional regarding wounds. Based on interviews which were conducted, record review, and observation the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. A copy of the appeal rights and this report provided.the state’s words, verbatim · CDSS document, Oct 14, 2025 · control 15-AS-20250624160351

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87616(a) · Plan of correction due date: Oct 21, 2025

(a) As specified in Section 87209... the licensee may submit a written exception request if he/she agrees that the resident has a prohibited ... health condition but believes that the intent of the law can be met through alternative means. This requirement was not met as evidence by: Based on interviews and documentation, the Licensee did not comply with the section cited above in requesting an exception before admitted a resident with a prohibited condition, which poses a health risk to person in care.the state’s words, verbatim · CDSS document, Oct 14, 2025

Plan of correction: Administrator agreed to review regulation 87616 and 87615. Administrator will submit self-certification that both have been read and they abide by the regulations going forward to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: Oct 21, 2025

(a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff... qualifications... to meet their needs. This requirement was not met as evidence by: Based on interviews and observation the Licensee did not comply with the section cited above in preventing R1 from obtaining wounds, which poses a health risk to person in care.the state’s words, verbatim · CDSS document, Oct 14, 2025

Plan of correction: Administrator agreed to implement a plan on how to prevent residents from developing pressure injuries. Plan needs to be submitted to CCL by POC date.

Type of visit: Case Management - Other

On 10/14/2025, at 5:05pm, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Annabel Danan, House Manager, and explained the purpose of the visit. While LPA L. Hall was conducting a complaint investigation 15-AS-20250624160351 on 10/14/2025. During record review LPA observed R1 and R2 had expired and the facility did not notify CCLD. LPA also reviewed after summary visits for R1 dated 1/24/2025 and 6/10/2025, and observed CCLD was not notified. The deficiency were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, Oct 14, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A) · Plan of correction due date: Oct 21, 2025

(a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... This report shall include the resident's name...and nature of event... (A) Death of any resident from any cause... This requirement was not met as evidence by: Based on record review the Licensee did not comply with the section cited above in reporting deaths and incidents to CCLD, which poses a potential personal rights issued to persons in care.the state’s words, verbatim · CDSS document, Oct 14, 2025

Plan of correction: Administrator agreed to submit death certificates for R1 and R2 to CCLD by POC date.

Type of visit: POC

On 5/8/2025, at 9:50am, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a proof of correction (POC) visit. LPA met with Annabel Danan, Caregiver, and explained the purpose of the visit. LPA spoke with Administrator Isagani Silvestre, via telephone. LPA conducted an annual inspection on 4/24/2025 and cited for the following deficiencies that has been corrected. 8465(h)(2) - Deficiency was cleared during visit on 4/24/2025. 87355(e)(3) - LPA observed S5 was associated on 4/27/2025. 87305(b) - Licensee submitted email stating garage was cleared of staff and sheds were locked on 4/30/2025. 87202(a)(2) - LPA observed resident was moved into room #1. Staff is now in #4. 87632(d)(2) - LPA observed hospice notifications were completed and emailed to LPA on 4/30/2025. 87211(a)(1) - Administrator submitted self-certification that regulation was read and facility will abide on 4/30/2024. Continued on LIC809C. Continued from LIC809. 87506(a), LPA observed staff records were complete. Self-certification was submitted on 4/30/2025. 1569.625(b)(2) - LPA observed staff have received annual training. Submitted 4/30/2025. All deficiencies have been cleared. Exit interview conducted. A copy of the plan of correction letters and this report provided.the state’s words, verbatim · CDSS document, May 8, 2025

Type of visit: Required - 1 Year

On 4/24/2025 at 3:20pm, Licensing Program Analyst LPA L. Hall conducted an unannounced annual required inspection. LPA met with Adelina Danieles, Caregiver, and explained the reason for the visit. Administrator, Ronan Rances, arrived at 3:15pm. The administrator currently holds a certificate (#7033979740) that expires on 03/6/2026. The facility’s fire clearance was approved for one (1) ambulatory and five (5) non-ambulatory. Hospice waiver for four (4). LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and backyard. The facility consists of five (5) bedrooms and two (2) bathrooms. No bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 110.4 degrees Fahrenheit. Night lights are maintained in hallways and passages. Residents’ bathrooms are equipped with grab bars no and non slip mats. Facility has a 7-day supply of perishables and 2-day non perishable foods available for residents. Continued on LIC809C. Continued from LIC809C Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 03/22/2025. Emergency Disaster Plan was last posted on 1/5/2025. First aid kit was observed to be complete. Fire drill was last conducted on 12/15/2024. Liability Insurance LIC308 Designation of facility responsibility LIC500 Personnel record LIC610E Emergency Disaster Plan (last page) LPAs observed the following deficiencies: At 3:25pm, LPA observed two (2) dinner trays sitting on kitchen table with medication in small canister. Trays had R1 and R2's name on it. At 3:35pm, LPA observed S5 residing in garage. At 3:35pm, LPA observed during record review S5 was not associated to the facility. At 3:53pm, LPA observed beige/white shed was being lived-in. LPA observed a bed with sheets and pillows, a motor scooter and suit cases. At 3:53pm, LPA observed storage area in garage being used as living quarters for two (2) staff (S2 and S3). At 4:30pm, LPA observed during record review R5 is bedridden and facility does not have a bedridden fire clearance. At 4:40pm, LPA observed during record resident records were incomplete. R1, R5, and R6 admission agreement was incomplete. All residents either did not have a consent or was not signed by representative. R2 and R5's physician's report was incomplete. Continued on LIC809C. Continued from LIC809C. At 5:00pm, LPA observed during record review R3 was hospitalized it was not reported to CCLD. At 5:00pm, LPA observed during record review only S5 had annual training. At 5:15pm, LPA observed during record review facility did not submit a hospice notification for R3 and R4 to CCLD. *An immediate civil penalty of $1000.00 will be assessed on today's date ($500.00 for 87355(e)(3) and $500.00 for 87202(a)(2)* Deficiencies cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy the appeal rights, LIC421BG, LIC421IM, and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 24, 2025

Type of visit: Case Management - Other

On 11/15/2024 at 3:55pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management. LPA met with Josephine Ambagan, Caregiver, and explained the purpose of the visit. Administrator, Ronan Rances, arrived at 4:00pm. LPA had received a denied fire clearance on 9/17/2024. LPA toured facility during visit and observed two (2) non-ambulatory residents residing in an ambulatory only room only. S1 stated repairs have been completed and he will be submitting documentation to CCLD. *An immediate civil penalty of $250.00 will be assessed on today's date for a repeat violation* Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of the appeal rights, LIC421FC, and this report provided.the state’s words, verbatim · CDSS document, Nov 15, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a)(1) · Plan of correction due date: Nov 16, 2024

(a) All facilities shall maintain a fire clearance approved by the... city and county fire department... Prior to accepting or retaining... persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county... (1) Non ambulatory persons. This requirement was not met as evidence by: This requirement was not met as evidence by: The LIcensee did not comply with the section cited above in having a fire clearance for five non ambulatory persons, which poses a health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 15, 2024

Plan of correction: Administrator agreed to implement a plan to relocate residents that are in ambulatory rooms or provide plan on corrections going forward, and submit to CCLD by POC date.

Type of visit: Required - 1 Year

On 5/3/2024 at 9:25am, Licensing Program Analysts LPAs L. Hall and T. Syess- Gibson conducted an unannounced Annual 1-year required inspection. LPAs met with Josephine Ambagan, Caregiver, and explained the reason for the visit. Administrator, Ronan Rances, arrived at 10:05am. The administrator currently holds a certificate (#6056425740) that expires on 07/15/2024. The facility’s fire clearance was approved for three (3) ambulatory and three (3) non-ambulatory. Hospice waiver for four (4). LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and backyard. The facility consists of five (5) bedrooms and two (2) bathroom. One (1) bedroom #5 is occupied by staff. No bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. A comfortable temperature is maintained at 73 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 120.1 degrees Fahrenheit. Night lights are maintained in hallways and passages. Residents’ bathrooms are equipped with grab bars no and non slip mats. Facility has a 7-day supply of perishables and 2-day non perishable foods available for residents. Continued on LIC809C. Continued from LIC809C Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 01/09/2024. Emergency Disaster Plan was last posted on 093/15/2024. First aid kit was observed to be complete. Fire drill was last conducted on 2/5/2024. Liability Insurance LIC308 Designation of facility responsibility LIC500 Personnel record LPAs observed the following deficiencies: At 9:45am, LPAs observed R4 and R5 are residing in ambulatory only rooms. At 9:45am, LPAs observed cameras for R3 and R4 in their bedrooms. At 9:50am, LPAs observed during record review hospice notification was not submitted for R2 and R5. At 10:00am, LPA observed a brick covering hole in bottom of kitchen cabinet. At 10:20am, LPA was informed facility has mice. At 11:00am, LPA observed during record review S4 did not have health screening or TB. Deficiencies cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy the appeal rights and a copy of this report provided.the state’s words, verbatim · CDSS document, May 3, 2024