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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097003989
Report Date: 03/10/2021
Date Signed: 03/10/2021 01:38:34 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:AT HOME SERENITY CAREFACILITY NUMBER:
097003989
ADMINISTRATOR:VINO-DEGUZMAN, MARYFACILITY TYPE:
740
ADDRESS:1660 DOWNIEVILLE COURTTELEPHONE:
(916) 933-7876
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY:6CENSUS: 0DATE:
03/10/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Mary Vino-DeGuzmanTIME COMPLETED:
01:45 PM
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Case management visit regarding closure of the facility. Licensee has decided to voluntarily close the facility. Walk through inspection revealed that the facility is empty and there are no residents in care. Licensee relinquished the CDSS license. License was retained by LPA. Facility will be closed in the CDSS database upon return to the office.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Michael SmithTELEPHONE: (916) 206-7807
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2021
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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