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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201663
Report Date: 09/29/2021
Date Signed: 09/29/2021 05:16:03 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:SERENITY LIVINGFACILITY NUMBER:
107201663
ADMINISTRATOR:JONES, JOSIANEFACILITY TYPE:
740
ADDRESS:2605 W. BARSTOW AVENUETELEPHONE:
(559) 449-0504
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY:6CENSUS: 3DATE:
09/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Josiane JonesTIME COMPLETED:
01:00 PM
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On 9/29/2021, Licensing Program Analyst(LPA) D. Ayers arrived at facility unannounced to conduct a Required Annual Inspection. LPA met with Licensee Josiane Jones. Administrator Certificate is current with renewal date 6/8/2022.

LPA toured facility inside and out. All passageways and exits are clear and free from obstruction. All smoke detectors and carbon monoxide detector were functional. Facility was adequately furnished and lit. LPA observed inside temperature to be 73 degrees F. LPA observed adequate supply of nonperishable and two day supply of perishable food stuffs. LPA observed chemicals and hazardous materials to be stored in locked cabinets in laundry room. Facility has multiple first aid kits which contain required items. Medication is secured in locked closet and appeared to be administered properly.

LPA toured resident bedrooms and bathrooms. All bedrooms were adequately furnished and lit. Bathrooms have secure grab bars and nonskid mats. LPA observed a sufficient supply of extra pillows and linens in hallway closets. Administrator agreed to provide LPA with LIC 610E and LIC 500 by 10/13/2021. Exit interview conducted and a copy of this report provided via email.
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: David AyersTELEPHONE: (559) 650-7925
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
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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