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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200967
Report Date: 04/24/2025
Date Signed: 04/24/2025 07:41:39 PM

Document Has Been Signed on 04/24/2025 07:41 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/
DIRECTOR:		RANCES, RONAN BFACILITY TYPE:
740
ADDRESS:2297 JACQUELINE DRIVETELEPHONE:
(925) 267-9084
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 6DATE:
04/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:20 PM
MET WITH:Adelina Danieles, CaregiverTIME VISIT/
INSPECTION COMPLETED:
08:00 PM
NARRATIVE
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On 4/24/2025 at 3:20pm, Licensing Program Analyst LPA L. Hall conducted an unannounced annual required inspection. LPA met with Adelina Danieles, Caregiver, and explained the reason for the visit. Administrator, Ronan Rances, arrived at 3:15pm. The administrator currently holds a certificate (#7033979740) that expires on 03/6/2026. The facility’s fire clearance was approved for one (1) ambulatory and five (5) non-ambulatory. Hospice waiver for four (4).

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and backyard. The facility consists of five (5) bedrooms and two (2) bathrooms. No bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 110.4 degrees Fahrenheit. Night lights are maintained in hallways and passages. Residents’ bathrooms are equipped with grab bars no and non slip mats. Facility has a 7-day supply of perishables and 2-day non perishable foods available for residents.

Continued on LIC809C.
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Laura Hall
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: SERENE CARE JACQUELINE
FACILITY NUMBER: 079200967
VISIT DATE: 04/24/2025
NARRATIVE
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Continued from LIC809C

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 03/22/2025. Emergency Disaster Plan was last posted on 1/5/2025. First aid kit was observed to be complete. Fire drill was last conducted on 12/15/2024.
  • Liability Insurance
  • LIC308 Designation of facility responsibility
  • LIC500 Personnel record
  • LIC610E Emergency Disaster Plan (last page)


LPAs observed the following deficiencies:
  • At 3:25pm, LPA observed two (2) dinner trays sitting on kitchen table with medication in small canister. Trays had R1 and R2's name on it.
  • At 3:35pm, LPA observed S5 residing in garage.
  • At 3:35pm, LPA observed during record review S5 was not associated to the facility.
  • At 3:53pm, LPA observed beige/white shed was being lived-in. LPA observed a bed with sheets and pillows, a motor scooter and suit cases.
  • At 3:53pm, LPA observed storage area in garage being used as living quarters for two (2) staff (S2 and S3).
  • At 4:30pm, LPA observed during record review R5 is bedridden and facility does not have a bedridden fire clearance.
  • At 4:40pm, LPA observed during record resident records were incomplete. R1, R5, and R6 admission agreement was incomplete. All residents either did not have a consent or was not signed by representative. R2 and R5's physician's report was incomplete.

Continued on LIC809C.
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Laura Hall
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC809 (FAS) - (06/04)
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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: SERENE CARE JACQUELINE
FACILITY NUMBER: 079200967
VISIT DATE: 04/24/2025
NARRATIVE
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Continued from LIC809C.
  • At 5:00pm, LPA observed during record review R3 was hospitalized it was not reported to CCLD.
  • At 5:00pm, LPA observed during record review only S5 had annual training.
  • At 5:15pm, LPA observed during record review facility did not submit a hospice notification for R3 and R4 to CCLD.

*An immediate civil penalty of $1000.00 will be assessed on today's date ($500.00 for 87355(e)(3) and $500.00 for 87202(a)(2)*

Deficiencies cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy the appeal rights, LIC421BG, LIC421IM, and a copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Laura Hall
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 04/24/2025 07:41 PM - It Cannot Be Edited


Created By: Laura Hall On 04/24/2025 at 06:52 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: SERENE CARE JACQUELINE
FACILITY NUMBER: 079200967

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in having a fire clearance for R5 to reside at the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2025
Plan of Correction
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Administrator agreed to submit LIC200 and a copy of the updated facility sketch to CCLD by POC date.
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in having S5 associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2025
Plan of Correction
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3
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Administrator agreed to associate S5 to the facility and advise LPA association has been completed by 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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Laura Hall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2025


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 04/24/2025 07:41 PM - It Cannot Be Edited


Created By: Laura Hall On 04/24/2025 at 06:52 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: SERENE CARE JACQUELINE
FACILITY NUMBER: 079200967

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(1)
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in reporting R3 hospitalization to CCLD which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2025
Plan of Correction
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Administrator agreed to review regulation and submit self-certification that the facility will abide by regulation going forward to CCLD by POC date.
Type B
Section Cited
CCR
87632(d)(2)
(d) If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver as necessary to ensure the well-being of terminally ill residents and of all other facility residents, which shall include, but not be limited to, the following requirements:

(2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in sending hospice initiation notification to CCLD for R3 and R4 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2025
Plan of Correction
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Administrator agreed to submit hospice initiation notfication for R3 and R4 to CCLD by 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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Laura Hall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/24/2025 07:41 PM - It Cannot Be Edited


Created By: Laura Hall On 04/24/2025 at 06:52 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: SERENE CARE JACQUELINE
FACILITY NUMBER: 079200967

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in having annual training for staff which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2025
Plan of Correction
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Administrator agreed to obtain training for each staff and submit self-certificaton that the training has been completed to CCLD by POC date.
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having each resident record complete which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2025
Plan of Correction
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Administrator agreed to complete each resident record and submit a self-certification to CCLD that it has been done by 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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Laura Hall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2025


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 04/24/2025 07:41 PM - It Cannot Be Edited


Created By: Laura Hall On 04/24/2025 at 07:09 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: SERENE CARE JACQUELINE
FACILITY NUMBER: 079200967

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
(h) The following requirements shall apply to medications which are centrally stored:

(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having medicaton inaccessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2025
Plan of Correction
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4
Caregiver immediately locked medication in locked kitchen cabinet. Deficiency cleared during visit.
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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Laura Hall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/24/2025 07:41 PM - It Cannot Be Edited


Created By: Laura Hall On 04/24/2025 at 07:18 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: SERENE CARE JACQUELINE
FACILITY NUMBER: 079200967

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(b)
(b) The licensing agency may require the facility to acquire a local building inspection where the agency determines that a suspected hazard to health and safety exists.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in having staff residing in storage are in garage, a corner of the garage, and the shed in the back yard which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2025
Plan of Correction
1
2
3
4
Administrator agreed to submit a LIC200 and updated facility sketch to CCLD 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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Laura Hall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2025


LIC809 (FAS) - (06/04)
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