SERENITY SENIOR RETREAT

Official classification

Type A

Official code

87307(a)(2)

Regulation authority

CCR

What the official deficiency says

Personal Accomodations and Services. (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room... (C) No bedroom of a resident shall be used as a passegeway to anothre room, bathe.... This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation and interviews, the licensee did not comply with the section cited above by placing a twin bed in bedroom #1 closet and twin bed in the garage by allowing the staff to use it as a resting/break room. This which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/04/2026 Plan of Correction Administrator will remove beds from the closet and garage. Proof of pictures along with the statement of understanding this Section will be submitted to LPA by POC date.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

Storage Spase and Access: (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs observation, the licensee did not comply with the section cited above by failing to lock the laundry and garage doors, where all chemicals and cleaning solutions were accessible to residents in care. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/04/2026 Plan of Correction During today's visit, the Co-Administrator locked the doors. Licensee/Administrator agreed to provide in-service training to all staff. Copy of the training will be submitted to LPA by POC date.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care: (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees for the supervision of the centrally strored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs inspection and observation, the licensee did not comply with the section cited above by failing to lock twenty-one (21) prefilled syringes of ready-to-administer, single-dose unit narcotic medication prescribed for R1 and four (4) over-the-counter staff medications in bedroom #1 closet. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/04/2026 Plan of Correction During todays visit, all medications were immediately locked. Licensee/Administrator will hire a licensed vendor and provide training to all staff. Vendor's credentials (name, license #, telephone) will be submitted to LPA by POC date. Training certificate will be submitted to LPA upon completion.

Official classification

Type A

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

Postural Support: (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs observation and file review, the licensee did not comply with the section cited above in Based on LPAs observation and record review, the licensee did not comply with the section cited above by failing to obtain a written Doctor's order for three (3) half bed rails for R2, R3 and R4. This poses an immediate health, safety to persons in care.

Official plan of correction

POC Due Date: 04/04/2026 Plan of Correction License/Administrator agreed to obtain a written Dr. order. Copies of orders must be submitted to LPA by POC date.

Official classification

Type A

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

Postural Supports: (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself... (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs observation and interview with the Co-Administrator, the licensee did not comply with the section cited above by having a full bed rail for R5 without an exception approval from the CCLD and proper Doctors order on file. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/04/2026 Plan of Correction Licensee/Administrator will obtain a written Doctor's order for a full bed rail. Copy of Dr's order will be submitted to LPA by POC date.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

Fire Clearance. a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by: Deficient Practice Statement Based on Fire Marshal Inspector's observation, the licensee did not comply with the section cited above by failing to maintain the conditions of the approved fire clearance with a proper occupancy code and 2 fire doors (in bedroom #1 and garage) were broken/damaged/malfunctioning, which poses an immediate health and safety risk to residents in care. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/04/2026 Plan of Correction Licensee/Administrator agreed to replace/fix two (2) fire doors and submit a request for change of occupancy through Building and Safety along with a new LIC200 with facility sketch to obtain a new Fire Clearance.

Official classification

Type B

Official code

87506

Regulation authority

CCR

What the official deficiency says

Resident Records (b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA file review, the licensee did not comply with the section cited above by not completing six (6) out of six (6) residnet files. Records were incomplete and or missing documents, which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 04/09/2026 Plan of Correction Licensee agreed to review and complete all facility residents' files. Written roster with resident name and date of file completion will be submitted to LPA by POC date.

Official classification

Type B

Official code

87412(c)

Regulation authority

CCR

What the official deficiency says

Personnel Records: (c) Licensees shall maintain in the personnel records verification of required staff training and orientation This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs record review, the licensee did not comply with the section cited above failing to provide proper training to all staff prior to employement. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/09/2026 Plan of Correction Licensee/Administrator agreed to provide in-service training to all staff (for the initial 20hrs) and submit copy of proof by POC date.

Official classification

Type B

Official code

1569.69(a)

Regulation authority

HSC

What the official deficiency says

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: This requirement is not met as evidenced by: Deficient Practice Statement Based on staff record review, the licensee did not comply with the section cited above in [2] out of [2] staff files, LPA did not observe medication training records for both staff. Which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/10/2025 Plan of Correction

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency...:(1) A written report shall be submitted to the licensing agency of the occurrence of...(D) any incident which threatens the welfare, safety or health of any resident... This requirement is not met as evidenced by: Based on interviews & record reviews, the licensee did not comply with the section cited above as the facility did not notify the responsible party and send an incident report to the Dept. which poses a potential health & safety risk & violation of personal rights to residents in care.

Official plan of correction

The Administrator will review Section 87211(a)(1)(D) and will inform in writing explaining how they will assure to follow Title 22 Regulations with regards to following reporting procedures.

Deadline recorded: Aug 31, 2022. A deadline is not proof that correction was completed.