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Inspection visit

Routine inspection

MOUNT HOOD SERENITY CARELicense 3427006965 citations on this visit
5 citations recorded

Inspector’s narrative

What the inspector wrote

Licensing Program Analyst (LPA) Talwinder Bains arrived on 05/01/25 to conduct the annual inspection. LPA met with staff Tonya Miles and explained the purpose of today's visit. LPA was notified by staff that administrator was not available today to assist with today's visit. LPA Cheyenne Ratajczak and Licensing Program Manager (LPM), Laura Munoz came after short while to assist with today's visit. Administrator Irene Nepomuceno arrived at 11:32 AM. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, and common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. LPA checked the kitchen area for the ability to prepare and store food. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Following issues were observed during today's visit: Medications accessible to residents, Staff working without fingerprint clearance, Department has no access to staff and residents records, no administrator accessible /working during today's visit, accessible knives, chemicals and laundry supplies to residents, and citations were issued as listed on LIC809-D. LPA requested a copy of the LIC308, LIC 500, LIC610E and current liability insurance to be sent to the Department by 05/15/25. Deficiencies were observed and cited per Title 22, CCR Regulations as listed on LIC 809-D. Civil penalties shall be assessed if facility does not comply with POC requirements which were issued today. Exit interview conducted. Copy of this report ,LIC809G and appeal rights were provided.

Citations

7 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87309(a)Type A

    Ensure hazardous items are locked and not unattended

    Based on facility tour, LPA observed chemicals and knives were accessible in kitchen which poses an immediate health, safety or personal rights risk to persons in care.

  • 87355(e)Type A

    Address and clearance obligations before facility work

    Based on record review, Department found out that staff, S1 was not fingerprint cleared and was working at the facility for 2 weeks which poses an immediate health, safety or personal rights risk to persons in care.

  • 87405(d)Type B

    Required administrator qualifications listed in this subsection

    Based on observation and interview, the licensee did not comply with the section cited above as facility administrator was not working/accessible during inspection which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87412(f)Type B

    Allow licensing inspection and controlled record removal

    Based on facility tour, staff interviews, staff have no access to residents and staff's records for Department audit, which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87465(h)(2)Type B

    Store centrally held medications in locked secure place

    Based on observation, the licensee did not comply with the section cited above as medications closet was found to be open and medications were accessible to residents, which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87203Type A

    Maintain facilities for fire and panic safety

    87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above as LPAs observed facility fire door to be propped open with a door stopper which poses an immediate health, safety or personal rights risk to persons in care.

  • 87211Type B

    Reporting requirements

    87211-Reporting Requirements- (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following... this requirement is not met as evidence by; Staff interview reflected that resident, R1 was sent out to hospital after fall incident with right hip fracture on 03/24/25 but facility did not report this incident to Department per requirement which poses a potential safety and health risks to residents in care.

FAQ · About this visit

Common questions about this visit

What happened during the May 1, 2025 inspection of MOUNT HOOD SERENITY CARE?

This was an inspection of MOUNT HOOD SERENITY CARE on May 1, 2025. 5 citations were issued: 2 Type A (serious) and 3 Type B.

Were any citations issued to MOUNT HOOD SERENITY CARE on May 1, 2025?

Yes, 5 citations were issued (2 Type A, 3 Type B). The first citation was for: "Based on facility tour, LPA observed chemicals and knives were accessible in kitchen which poses an immediate health, sa..."

What type of inspection was this?

This was an inspection. Inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.