SERENITAS CARE, LLC

Official classification

Type A

Official code

87628(a)

Regulation authority

CCR

What the official deficiency says

87628 Diabetes (a)The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing ...or has it administered by an appropriately skilled professional. This requirement is not met as evidenced by: Based on record review & interviews R2 and R3 are not able to perform their own glucose testing due to developmental disability. S2 and S3 stated they administer sharp lancet glucose test to R2 and R3, which pose/s a immediate health, safety and personal right risk to persons in care.

Official plan of correction

ADM stated he/she shall submit a memorandum of understanding that staff will adhere the rules and regulations as stipulated on PIN 17-09-ASC in administering finger prick glucose testing by the POC due date of 08/12/2026.

Deadline recorded: Aug 12, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87612(a)(5)

Regulation authority

CCR

What the official deficiency says

87612 Restricted Health Conditions (a) The licensee may provide care for residents who have any of the following restricted health conditions, or who require any of the following health services: (5)Diabetes as specified in Section 87628. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and interviews on 08/04/2026, the licensee did not obtain a Department exception before staff provided restricted care to R3 and R1. Staff began daily glucose testing on 09/09/24 & restarted on 10/15/25. S2 & S3 stated they perform finger pricks and operate the monitor. Per PIN 17-09-ASC, staff device manipulation constitutes administration, not self-testing, which pose/s a potential health, safety and personal right risk to persons in care. THIS CITATION IS BEING AMENDED ON NEW LIC 809 D.

Official plan of correction

POC Due Date: 08/18/2026 Plan of Correction ADM stated he/she shall submit a complete Restricted Health Condition Exception packet for diabetes (Title 22 CCR § 87612(a)(5)) PA by 08/18/2026. The packets will include physician orders, specific high/low response protocols, and signed staff training logs proving monitor competency. Any restricted health tasks will not be initiated without prior Department approval. THIS SECTION IS BEING AMENDED DUE TO NEW INFORMATION SEE NEW LIC 809D

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements – General (f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician ... A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents... This requirement is not met as evidenced by: Deficient Practice Statement Based on records reviewed, the licensee did not comply with the section cited above. Staff S1's health screening doesn't have the identifying information for the physician who did the health screening. LPA requested to reviewed staff S2's health screening. ADM did not provide LPA with a copy of S2's health screening. ADM stated S2 would get an updated, by next week. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/05/2025 Plan of Correction ADM stated she would get a new health screening for Staff S1 and S2. ADM stated she would send LPA a copy of the updated health screenings to LPA by POC date, September 5, 2025.

Official classification

Type B

Official code

8741(c)(6)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive ... annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (6) ...maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2). For on-the-job training, documentation ... This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited 2 of 2 staff record that was reviewed did not maintain documentation of annual training required on based on Health and Safety Code sections 1569.625 and 1569.69(6) which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/23/2024 Plan of Correction Administrator stated the training will be adminstered to staff and proof of trainingwill be submitted to LPA by the POC due date.