Serenity Senior Retreat

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Angela Panushkina, Huma Rahimi, along with the Fire Inspector, Frank Madugno and Building Engineering Inspector, Robert Hagen, conducted an annual-continuation inspection and met with the Co-Administrator and explained the reason for the visit. The facility is Fire Clearance was approved in 10/22/2019 for the capacity of one (1) Bedridden and one (1) Non-Ambulatory residents in room #1, two (2) Non-Ambulatory residents in room #2, one (1) Non-Ambulatory resident in room #3 and one (1) Ambulatory in room #4. A tour of the physical plant was initiated at 10:15am and the following were observed: The facility maintains a comfortable temperature at 68°F. The facility has four (4) bedrooms designated for residents’ use. All bedrooms are furnished with beds and dressers and required bedding and linen. The bedrooms have sufficient closet space and lighting. Auditory alarms were tested and observed to be operational. The team observed a twin bed in bedroom #1’ closet. The Co-Administrator informed the team that the staff are using the closet area as a resting area for breaks. The team also observed four (4) bottles of vitamins/over-the-counter medications along with Raid and disinfectant sprays placed on the table, unlocked inside the walking closet. Additionally, self-closing fire door hinge was loose/broken and had a stopper underneath the door to prevent from closing during the emergency. The Co-Administrator was informed to replace/repair the door. Lastly the team observed R1 had a full bed rail with no doctors' order/exception of file, double ½ (half) bed rails (making one full bed rail) for R2 with no doctors' order on file, ½ (half) bed rail for R4 with no doctors' order on file and ½ (half) bed rail for R3 with no doctors' order on file. Deficiency will be issued. Continue on LIC809-C There are three (3) full bathrooms. All bathrooms were observed to be clean and in good repair. Properly supplied with toilet paper, soap and paper towels. The hot water temperature measured at 113.2°F. Appropriate grab bar and non-skid mat were also observed. All trash cans in bathrooms had fitted lids to protect them from cross contamination. Extra towels and linens were readily available. The facility has a kitchen area that is equipped with a refrigerator, microwave oven and sink. The team observed there to be sufficient stock of one-week perishable foods and two-day non-perishable foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. At 11:20am, LPAs observed twenty-one (21) prefilled syringes of ready-to-administer, single-dose unit narcotic medication prescribed for R1. The fire extinguisher is located in the kitchen and was last serviced on 07/25/2023. Deficiency will be issued. At approximately 11:30am, LPAs observed medications are centrally stored and locked, in the kitchen cabinet, and inaccessible to residents in care. The first-aid kit has been inspected which has at least the following: tweezers, scissors, antiseptic, bandages, gauze, thermometer; including a current First Aid manual. The laundry room is located by the garage. The washer/dryer appears to be in good condition. The laundry area was observed to be unlocked, and all laundry supplies and chemicals were accessible to residents in care. The team observed another twin bed in the garage. The Fire Inspector informed the Co-Administrator that the garage is not approved for a habitable space. Additionally, the Fire Inspector informed the Co-Administrator that the occupancy for the facility is incorrect, and new Fire Clearance is required at this time. The Deficiency will be issued. These include a dining area and a living room. The Common areas are furnished with adequate furniture to accommodate a maximum capacity of six (6) residents. At 11:40am, smoke and carbon monoxide detectors were tested and observed to be operable. There were no visible immediate hazards. At approximately 11:45am LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. LPA discussed the importance of maintaining care and supervision to meet the needs of clients. There are no bodies of water. Between 12:30pm to 1:30pm, LPA reviewed records of six (6) residents and two (2) staff. Resident and staff records appeared to be incomplete (missing forms, signatures, dates and S1's & S2's initial training). Deficiency will be issued. LPA collected Certificate of Liability Insurance and LIC500. Exit interview conducted. Appeal rights explained and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Apr 2, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tuesday Cabiness attempted to conduct an unannounced annual visit, for the facility's one year required inspection. LPA was greeted by caregiver Glenda Dulay who allowed LPA to enter. LPA explained the reason for the visit, who contacted Administrator Jilska Perera who arrived during the inspection. Shortly after Errol Fernando arrived. Due to tensions and hostility between the Administrator and husband Error Fernando towards LPA, who will attempt to conclude annual inspection at another time. Several citations and deficiencies were noted during the visit, which will be issued at the annual continuation. The following citations were observed: 1. Administrator qualifications - LPA determined the Administrator on file is not fulfilling the required amount of hours at the facility. 2. Residents 1 -3, were observed to have full bed rails. Documentation was not able to be verified. 3. LPA observed staff sleeping in room #1's closet in a bed, and there are mattresses in the garage observed for staff to sleep. LPA will also request an informal with management, pertaining to staff Errol recording conversations and what occurred during the visit. Exit conducted, copy of report given to Administrator's husband Errol Fernando. This report was amended to delete the 9099C pagethe state’s words, verbatim · CDSS document, Mar 14, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tuesday Cabiness conducted an unannounced visit, for the facility's one year required annual inspection. LPA was greeted by caregiver Glenda and Desiree Dulay, who allowed LPA to enter. LPA explained the reason for the visit and contacted Co-Administrator Errol Fernando. The annual inspection included: Common Areas: Living/dining/family room furniture were checked. The living room is neat and clean. The facility maintains a comfortable temperature at 75°F. The smoke detectors are hardwired and interconnected and observed to be operational. There is a carbon monoxide installed at the facility. Fire extinguisher is located in the dining area and observed to be full and charged. The living room was clear of clutter, furnished with couches and recliners to sit the capacity of the facility. 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 cabinet by the kitchen. There is an extra fridge in the garage, stocked with food. 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. The backyard of the facility has outdoor furniture, with a covered shaded area for clients. There is no body of water in the facility. There are (2) exit gates that were easily accessible. Passageways were clean and unobstructed. The garage is attached to the house. The garage is currently being used as rest area and storage for old equipment, chemicals, and supplies. Laundry room attached to the garage where LPA observed laundry detergents, cleaning agents and other toxins are stored in a locked cabinet in the laundry area. The laundry room was observed to be locked during visit. The bathroom was checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the toilet and shower area. The hot water temperature was measured at 113.7°F. Towels and washcloths are not shared. LPA observed non-skid mats and shower chairs. Medications: LPA observed medication in the dining area cabinet to be locked and inaccessible to residents. There were two (2) complete first aid kits with manual observed. Client records: Client records were reviewed. Residents record appeared to be complete and current. Staff records: LPA conducted a complete file review of staff records. Staff records appeared to be complete and updated, except yearly and medication training could not be verified. LPA was told they would email documentation. Technical assistance violations and citation were issued. Disaster drill was last conducted on 01/11/2025. Citation and technical violations issued, appeals rights, exit interview conducted, and copy of this report issued.the state’s words, verbatim · CDSS document, Jan 27, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Gary Tan, met with co administrator Errol Fernando for a One (1) Year Required visit for this facility. LPA explained the reason for the visit. A tour of the physical plant was conducted at 1:52 PM and the following was noted: There is only one entrance being utilized at the facility, there are required poster posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Infection Control and Mitigation plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside and inside. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room. The facility has four (4) bedrooms and three (3) bathrooms currently occupying four (4) residents. The facility is fire cleared for three (3) non-ambulatory residents one (1) of which may be bedridden on Room #1 and three (3) ambulatory. Hospice waiver for six (6) residents Living and dining room furniture were also checked. The living room is neat and clean. The facility maintains a comfortable temperature at 75°F. The smoke detectors are hardwired and interconnected and observed to be operational. There is a carbon monoxide installed at the facility. Fire extinguisher is located in the dining area and observed to be full and last inspected on 07/25/23. The backyard of the facility has outdoor furniture, with a covered shaded area for clients. There is no body of water in the facility. (continued on LIC 809-C) (continued on LIC 809-C) The garage is attached to the house. The garage is currently being used as staff rest area and storage for old equipment, frozen foods, PPE and other toxins. Laundry room is located on a small room on the way to the garage, Laundry detergents, cleaning agents and other toxins are stored in a locked cabinet in the laundry area. The laundry room was observed to be locked during visit. Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents. The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit. Clients have sufficient amounts of personal hygiene product which is provided by the licensee. The bathroom was checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the toilet and shower. The hot water temperature was measured at 112.5°F. Towels and washcloths are not shared. There was enough clean linen available in stock at the cabinet. Medications: LPA observed medication in the dining area cabinet to be locked and inaccessible to residents. There were two (2) complete first aid kits located in the medication cabinet. Client records: Client records are reviewed. Residents record appeared to be complete and current. Staff records: LPA conducted a complete file review of staff records. Staff records appeared to be complete and updated. Disaster drill was last conducted on 11/28 /23. Required posting observed in facility (complaint hot line poster). Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Jan 7, 2024