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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200887
Report Date: 04/02/2024
Date Signed: 04/02/2024 04:30:38 PM

Document Has Been Signed on 04/02/2024 04:30 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
OAKLAND ASC, 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: 4DATE:
04/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Caregiver, Jayson RamosTIME COMPLETED:
04:40 PM
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On 4/2/2024 at 2:00 PM, Licensing Program Analyst (LPA's) A. Gomez and A. Gharachorloo arrived unannounced to conduct 1-Year Annual Required Inspection. LPAs met with Caregiver, Jayson Ramos and explained the purpose of the visit. Administrator,Edith Sarmiento arrived 2:45 PM. The facility’s fire clearance was approved for 6 ambulatory.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which 4 bedrooms are occupied by the clients and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 71 degree Fahrenheit. 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 111 degree Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygienes were available for clients. There is a minimum of one week supply of non-perishables and 2-day perishables food supply.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 05/19/2023. Emergency Disaster Plan was last posted on 04/02/2024. First aid kit was observed to be complete. Fire drill was last conducted on 03/02/2024.

At 2:30 pm, 4 of clients records were reviewed. At 3:00 PM 4 staff records were reviewed and 4 of 4 have current first aid training and are associated to the facility.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2024
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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