Serenity Villa

Allegation investigated: Staff did not ensure that medication was inaccessible to residents Licensee is not following reporting requirements

Licensing Program Analysts (LPA'S ) Melina Oropeza and Kesha Lewis arrived unannounced to continue complaint investigation regarding the allegations noted above. LPA'S met with the administrator, Luz Garibay LPA’s explained the purpose of the visit. Staff did not ensure that medication was inaccessible to residents. LPA observed medications properly stored in a locked and secured area inaccessible to residents. The medication storage key was maintained by administrator and inaccessible to residents. LPA observed administrator access the locked medication closet, re-secure the area, pour medication, and administer medication to a resident. Licensee is not following reporting requirements. Record review revealed no evidence that the licensee failed to follow reporting requirements. Incident occurred on 04/06/26 and administrator reported to CCL on 04/08/26. Incident was reported on time to the appropriate agencies. Unsubstantiated Based on observations and record review, the allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations occurred. Exit interview was conducted and a copy of the report was given the administrator, Luz Garibay. No citations were issued per Title 22 regulations.the state’s words, verbatim · CDSS document, Jul 9, 2026 · control 27-AS-20260413132003

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Melina Oropeza and Kesha Lewis arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection Visit. LPA was met by administratorr. LPA explained the purpose of the visit to Administrator. Administrator certificate # 6072036740 expires 08/28/2026. The facility is approved for 6 non-ambulatory; waiver/granted for 4 hospice care. Currently, 2 hospice in care. The facility currently has 2 dementia clients and a plan of op to serve dementia. LPA and administrator inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed facility with a current census of 2. There is entry door is leading to the living room, kitchen with a hallway to the bedrooms and bathrooms. Chemicals and medications noted to be locked to residents in care. No bodies of water were observed at the facility. Hot water temperature was measured at 106 F degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees Fahrenheit. All necessary documents were in place. LPA observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils. LPA observed the facility to have adequate food supply of 7 days non-perishables and 2 days perishables in place. Resident rooms were sanitary and had the required furniture and furnishings. No mal odors were observed. LPA observed, fire extinguishers inspected on 01/13/26 and current, smoke and carbon monoxide detectors, central heating and air in the facility. The first aid kit was found in compliance. LPA reviewed two (2) staff files. All staff is fingerprint cleared and associated to the facility and staff have current First Aid or CPR certifications on file. Facility is conducting initial and continuing training as required. LPA reviewed two (2) resident facility files and survey binder. All necessary documents were in place. Exit interview held with administrator and copies of reports left at conclusion of visit.the state’s words, verbatim · CDSS document, Jul 9, 2026

Allegation investigated: Staff left residents unsupervised Staff did not ensure that residents' incontinence needs were met Licensee is not following plan of operation

Licensing Program Analysts (LPA'S ) Kesha Lewis and Melina Oropeza arrived unannounced to open a complaint investigation regarding the allegations noted above. LPA'S met with the staff member, Claudia Castillo LPA’s explained the purpose of the visit. Staff left residents unsupervised based on interviews with licensee and staff along with video survelliance. S1 was seen leaving the facility and was the only one on duty. Therefore, the allegation is SUBSTANTIATED. Staff did not ensure that residents' incontinence needs were met based on interview with licesnsee. When they arrived at facility residents were soiled.Therefore,the allegation is SUBSTANTIATED. Licensee is not following plan of operation based on plan of operation, staff member is to be present at all times. Residents are not to be left unsupervised. Therefore, the allegation is SUBSTANTIATED. Substantiated It was determine the ponderance of the evidence standard has been met, therefore the above allegations are found to be substantiated. California code of regulations are being cited on LIC 9099-D. Appeals rights have been provided and an exit interview has been conducted to discuss the findings. Staff did not ensure that medication was inaccessible to residents based on observation medication cabinet is locked and medications in the refrigerator is in a locked box. Licensee is not following reporting requirements based on interview with licensee, they reported the incident to the officer of the day and sent a serious incident report to the department on 04/10/2026.the state’s words, verbatim · CDSS document, Apr 21, 2026 · control 27-AS-20260413132003

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Apr 22, 2026

(f) Basic services shall at a minimum include: 87464 (f) (1) Basic services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code Based on observation, file review, and interview with the administrator did not ensure staff provide care and supervision to R1. Leaving reditents R1-R3 at the facility alone.the state’s words, verbatim · CDSS document, Apr 21, 2026

Plan of correction: Administrator agrees to conduct basic services training for all staff. Administrator will read the regulation cited and provide LPA Oropeza a letter of acknowledgement that the regulation cited was reviewed. Administrator will email documents used for training and sign in sheet by POC Date 04/22/2026 by end of day 5:00pm.

Type of visit: Post Licensing

Unannounced Post Licensing visit made out to this facility on 04/21/2064 by Licensing Program Analyst (LPAS) Kesha Lewis and Melina Oropeza. This LPAS were met by the facility staff and informed the licensee via phone of the visit Current census was 3 residents. It was learned that there are 2 residents under the care of hospice at this time. This facility does have an approved waiver to be able to accept and retain up to (4) residents under the care of hospice at any given time. Tour of this facility was conducted. Dining area, living area, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Linen closet, located in facility hallway closet, was reviewed and observed to contain a sufficient supply of towels, sheets, and bedding able to meet the needs of the residents at this time. Kitchen area was toured. Kitchen drawers and cabinets were opened and reviewed. Food supply for 2-day perishable and 7-day nonperishable quantities was reviewed to make sure that they were in compliance at all times. Pantry area was toured Laundry area, located in the room next to the garage, was toured. Bleach, detergent, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time. Medication cabinets, located in the facility living area, was observed to be locked and made inaccessible to the residents at this time. First aid kit, was reviewed. Fire extinguishers were located in the facility and observed to have been services on 01/13/2026, with the, and are in compliance at this time. Facility resident bedrooms were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Facility resident restrooms were toured. Grab bars and non skid mats were observed to be present and in good repair at this time. Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees. A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gates, and all other exits was conducted. The following forms and documents were requested to be updated and submitted into CCL for review by this LPA: LIC 308 LIC 400 LIC 500 LIC 610 By COB on 4/24/2026. There were no deficiencies observed or cited during today's post licensing visit. Exit Interview and copy of report given.the state’s words, verbatim · CDSS document, Apr 21, 2026

Type of visit: Prelicensing

Announced Prelicensing visit made out to this facility on 07/03/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Luz Garibay, and Aileen Grimesey at this time. A brief interview was conducted with the facility designated Administrator at this time. It was learned that this facility was seeking licensure to accept and retain up to 6 non ambulatory residents at any given time. This facility does have an approved hospice waiver for (4) residents along with a dementia program that was submitted at this time. Current census was 0 residents. Tour of this facility was conducted. A tour of the facility kitchen area was conducted. Drawers and cabinets were opened and the items enclosed were reviewed at this time. Drawers housing knives and sharps were observed to be locked and made inaccessible to the residents at this time. Cleaning agents, bleach, and other supplies were observed to be locked and made inaccessible to the residents at this time. A review of the facility food supply was conducted. A review of the facility's 2-day perishable foods and 7-day nonperishable foods was conducted to make sure that there were sufficient quantities on hand at all times. Medication cabinet, located in the living room area, was reviewed. Policies and procedures involving handling, dispensing, and documentation of the resident medications were discussed with the facility designated Administrator at this time. A review of the facility Medication Administration Record and dispensing log was conducted. Medication cabinet was observed to be locked and made inaccessible to the residents at this time. Living room, dining area, and all other areas intended for resident use were observed to furnished and maintained in compliance at this time and able to meet the needs of the residents. A tour of the resident bedrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Facility resident restrooms were toured. Grab bars and non skid mats were observed to be present and in good repair at this time. Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees. Laundry room was toured at this time. Bleach, detergent, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time. Administrator certificate, # 6072036740 for Luz Garibay was observed to have an expiration date of 08/28/2026 and in compliance at this time. Forms and documents were being updated in order to renew this Administrator certificate at a later time. First aid kit, located in the medication cabinet, was reviewed. This LPA observed that it did contain all of the required components at this time. Fire extinguisher was observed to have been annually inspected by the local fire extinguisher company, Vallejo Fire Extinguisher Company, on 01/14/2025 and found to be in compliance at this time. Garage area was toured at this time. It was learned that this area would not be utilized by the residents at this time. A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gates, and all other exits was conducted. A review of the sample facility resident files was conducted. A review of the sample facility personnel files was conducted. This facility was observed to be in compliance at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Jul 3, 2025