107203958-4-25-2022-24-AS-MYAG-CDU33Y-20220425175418

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107203958
Report Date: 04/25/2022
Date Signed: 04/25/2022 05:54:21 PM

Document Has Been Signed on 04/25/2022 05:54 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, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	SERENITY LIVING II		FACILITY NUMBER:	107203958
ADMINISTRATOR:	JOSIANE P JONES		FACILITY TYPE:	740
ADDRESS:	1770 W. SAN JOSE AVENUE		TELEPHONE:	(559) 436-0211
CITY:	FRESNO	STATE: CA	ZIP CODE:	93711
CAPACITY:	6	CENSUS: 4	DATE:	04/25/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	04:15 PM
MET WITH:	Josiane P Jones, Administrator		TIME COMPLETED:	06:00 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

On 4/25/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with administrator. LPA met with Alejandrin Rivera, Caregiver. Administrator Josiane Jones was called and arrived shortly and conduct tour with LPA. All four residents were present during the inspection.

Upon entry facility staff was observed with facial covering. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. Social distancing and cough etiquette postings not observed.

LPA observed small amount of PPE supplies in facility. 30 days PPE supplies storage in a central location. Food supply was checked and appeared to be an adequate supply. Cleaning supplies were stored and locked in cabinet in the garage. All resident’s room toured and observed to be adequately furnished and lit. LPA observed 4 bedrooms that are single occupant and 1 vacant bedroom. All bathrooms are observed with securely fastened grab bars and non-skid mat. All bathrooms observed trash bin with lid. LPA observed hand washing posting by bathroom sinks.

The exterior tour was conducted. Side gate was self-closing and self-latching. LPA checked residents’ locked medications. Staff records were reviewed for good health and infection control training. All resident records reviewed to have updated emergency contact information.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 5/2/22. The following updated forms were requested: Lic 308, Lic 309, Lic 500, Lic 610E, Lic 808, and current liability insurance. LPA received copy of Lic 9020. A copy of this report was provided to the Administrator.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 3 of 3