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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200967
Report Date: 05/12/2023
Date Signed: 05/12/2023 05:47:13 PM

Document Has Been Signed on 05/12/2023 05:47 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:SERENE CARE JACQUELINEFACILITY NUMBER:
079200967
ADMINISTRATOR:RANCES, RONAN BFACILITY TYPE:
740
ADDRESS:2297 JACQUELINE DRIVETELEPHONE:
(925) 267-9084
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 3DATE:
05/12/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Ronan Rance, AdministratorTIME COMPLETED:
05:50 PM
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On 5/12/2023 at 3:00PM, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual 1-year required inspection. LPA met with Administrator, Ronan Rance, and explained the purpose of the visit.

During visit LPA cited facility but didn't add the following:

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code. Failure to correct deficiencies by POC date and/or any repeat deficiencies within a 12-month period may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

LPA created LIC809 to complete inspection.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2023
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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