<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200538
Report Date: 08/14/2024
Date Signed: 08/14/2024 02:19:42 PM

Document Has Been Signed on 08/14/2024 02:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:SERENITY HOMEFACILITY NUMBER:
019200538
ADMINISTRATOR/
DIRECTOR:		LEONIDA RAMOSFACILITY TYPE:
735
ADDRESS:42938 CHARLESTON WAYTELEPHONE:
(408) 887-8106
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 6CENSUS: 6DATE:
08/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Josephine Vargas- Direct Staff LeadTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 08/14/2024 at 10:00 am, Licensing Program Analysts (LPAs) Carol Fowler and Patricia Manalo conducted an unannounced annual 1-year required inspection. LPA met with Josephine Vargas, Direct Staff Lead and explained the purpose of the visit. Administrator, Edith Sarmiento, arrived at 10:50 am. The administrator currently holds a certificate (#6002437735) that expires on 06/12/2025. The facility’s fire clearance was approved for two (6) ambulatory.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, storage room, garage, and back yard. The facility consists of 3 bedrooms (3) and a total of two (2) bathrooms. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained. LPAs observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 104.4 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguishers were last services on 05/13/2024. Fire drill last conducted 02/25/2024. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 08/14/2024 02:19 PM - It Cannot Be Edited


Created By: Carol Fowler On 08/14/2024 at 01:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SERENITY HOME
FACILITY NUMBER: 019200538

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(1)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (1) An individual bed, except that couples shall be allowed to share one double or larger sized bed, maintained in good repair, and equipped with good bed springs, a clean mattress and pillow(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations, the licensee did not comply with the section cited above in having a worn mattress locating in bedroom #3 which poses a potential health and safety to persons in care.
POC Due Date: 08/28/2024
Plan of Correction
1
2
3
4
Administrator agree to purchase a new mattress for bedroom #3 and submit invoice to the department by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SERENITY HOME
FACILITY NUMBER: 019200538
VISIT DATE: 08/14/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC809.

three (3) staff records were reviewed, and all staff have first aid certification. Three (3) clients' records reviewed, current, and complete. LPAs reviewed P&I.

The following forms to be updated and submitted to CCLD by 08/24/2024:
  • Liability insurance.
  • Surety Bond
  • LIC500 (Personnel Record)
  • Client Roster
  • LIC308 (Designation of facility Responsibility)
  • LIC400 Affidavit Regarding Client/Resident Cash Resources
  • Updated facility sketch.


LPA observed the following deficiencies:
  • At 10:40A.M, LPAs observed mattress has a dip in the middle in room #3.
  • At 11:05 A.M, LPAs observed room created in the garage not on facility sketch.
  • At 11:06 A.M, LPAs observed car seat, plastic drawers, fans, lawn mower, two weed eaters, chairs, exercise equipment, washing machine, shower chairs, gardener hoe, boxes with Styrofoam.

The deficiencies was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/14/2024 02:19 PM - It Cannot Be Edited


Created By: Carol Fowler On 08/14/2024 at 01:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SERENITY HOME
FACILITY NUMBER: 019200538

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation the licensee did not comply with the section cited above in having a car seat, plastic drawers, fans, lawn mower, two weed eaters, chairs, exercise equipment, washing machine, shower chairs, gardener hoe, boxes with Styrofoam which poses a potential health and safety risk to persons in care.
POC Due Date: 08/28/2024
Plan of Correction
1
2
3
4
Administrator agrees to remove car seat, plastic drawers, fans, lawn mower, two weed eaters, chairs, exercise equipment, washing machine, shower chairs, gardener hoe, boxes with Styrofoam and submit photos to the department by POC date.
Type B
Section Cited
CCR
80086(a)(b)
(a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change. (b)The licensing agency shall have the authority to require that the licensee have a building inspection by a local building inspector if the agency suspects that a hazard to the clients' health and safety exists.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation the licensee did not comply with the section cited above in altering the garage adding a room that's not on the facility sketch, which poses a potential health and safety risk to persons in care.
POC Due Date: 08/21/2024
Plan of Correction
1
2
3
4
Administrator agree to provide the department with a LIC200 and updated facility sketch by the POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024


LIC809 (FAS) - (06/04)
Page: 4 of 4