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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200887
Report Date: 11/30/2022
Date Signed: 11/30/2022 12:22:16 PM

Document Has Been Signed on 11/30/2022 12:22 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 HOME IIFACILITY NUMBER:
019200887
ADMINISTRATOR:SARMIENTO, EDITHFACILITY TYPE:
735
ADDRESS:40429 FOSTER STREETTELEPHONE:
(510) 731-7822
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 6CENSUS: 3DATE:
11/30/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:57 AM
MET WITH:SARMIENTO, EDITH- AdministratorTIME COMPLETED:
12:25 PM
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On 11/30/2022, at 11: 57 AM, Licensing Program Analysts (LPAs) Liridon Fici and Catherine Lin conducted an unannounced case management visit to deliver the amended report dated for 11/18/2022. LPAs met with SARMIENTO, EDITH, Administrator (ADM) and explained the purpose of the visit.

During visit, LPAs delivered the amended report dated 11/30/2022. The facility ADM was given one page of the report, without the Lic9099-C page on 11/18/2022.



Exit interview conducted with Administrator and copy of this report provide.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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