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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200967
Report Date: 11/15/2024
Date Signed: 11/15/2024 05:02:45 PM

Document Has Been Signed on 11/15/2024 05:02 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: 5DATE:
11/15/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:55 PM
MET WITH:Josephine Ambagan, CaregiverTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
NARRATIVE
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On 11/15/2024 at 3:55pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management. LPA met with Josephine Ambagan, Caregiver, and explained the purpose of the visit. Administrator, Ronan Rances, arrived at 4:00pm.

LPA had received a denied fire clearance on 9/17/2024. LPA toured facility during visit and observed two (2) non-ambulatory residents residing in an ambulatory only room only. S1 stated repairs have been completed and he will be submitting documentation to CCLD.

*An immediate civil penalty of $250.00 will be assessed on today's date for a repeat violation*

Deficiency is 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 of the appeal rights, LIC421FC, and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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 2
Document Has Been Signed on 11/15/2024 05:02 PM - It Cannot Be Edited


Created By: Laura Hall On 11/15/2024 at 04:28 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: 11/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/16/2024
Section Cited
CCR
87202(a)(1)

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(a) All facilities shall maintain a fire clearance approved by the... city and county fire department... Prior to accepting or retaining... persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county... (1) Non ambulatory persons. This requirement was not met as evidence by:
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Administrator agreed to implement a plan to relocate residents that are in ambulatory rooms or provide plan on corrections going forward, and submit to CCLD by POC date.
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This requirement was not met as evidence by:
The LIcensee did not comply with the section cited above in having a fire clearance for five non ambulatory persons, which poses a health and safety risk to persons in care.
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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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2024


LIC809 (FAS) - (06/04)
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