107208950-6-14-2024-24-AS-LPAT-D68RCY-20240614125507

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107208950
Report Date: 06/14/2024
Date Signed: 06/14/2024 12:55:12 PM

Document Has Been Signed on 06/14/2024 12:55 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	SERENITY GARDEN HOME 2		FACILITY NUMBER:	107208950
ADMINISTRATOR:	FLORES, GINA ONAG		FACILITY TYPE:	740
ADDRESS:	5409 E BUTLER AVE		TELEPHONE:	(559) 478-4504
CITY:	FRESNO	STATE: CA	ZIP CODE:	93727
CAPACITY:	6	CENSUS: 6	DATE:	06/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Gina Flores, Licensee		TIME COMPLETED:	01:00 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	Licensing Program Analyst (LPA) Lissett Padgett arrived unannounced to conduct the Annual inspection. LPA introduced herself and explained the purpose of the visit, granted entry by Caregiver Isagani Colocado. Licensee, Gina Flores was called and arrived shortly thereafter. Facility was toured with Caregiver, Isagani Colocado. During this visit, LPA toured the facility and grounds. During this visit, there were 5 residents present. There are 6 resident rooms, all contained required furnishings and lighting and a TV. There are 3 bathrooms in this facility. LPA observed grab bars in shower and around toilet, non skid mat in showers, shower chair, trash can with lid. Hot water measured accordingly: Bathroom 1: 105.3 degrees F, Bathroom 2: 111.7 degrees F and Primary bathroom 113.7 degrees F. Resident hygiene supplies were properly stored and available. The kitchen was toured observed in good repair with necessary items and appliances and sharps/knives are stored in locked drawer. Cleaning products and dish soap are stored in locked cabinet. Refrigerator was observed to be at 40 degrees F and Freezer at 0 degrees F. Fire extinguisher attached to wall was serviced on 3/22/2024. LPA observed 2 day perishable and 7 day non perishable food supply available. No expired food observed. Medications are centrally stored and locked. Facility has designated visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility. Garage is kept locked. LPA observed locked medication refrigerator and extra refrigerator for food. Shelves store extra incontinence supplies and PPE supplies.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lissett Padgett	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SERENITY GARDEN HOME 2	FACILITY NUMBER: 107208950
	VISIT DATE: 06/14/2024

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First aid kit found to contain required items.

Laundry room is kept locked. LPA observed the room and appliances to be in good condition. Cleaning products are stored in locked cabinet.

Fire Extinguishers are located throughout the facility and were serviced in on 3/22/2024. Smoke and Carbon Monoxide detectors are located in each bedroom and in the common areas. Smoke/carbon detectors was tested and found to be functioning; they are interconnected.

The backyard is well maintained, trees, bushes and grass in good condition. There is a screened pergola with seating for 5. Patio furniture is clean and ready for use. In a separated fenced area LPA observed a shed with are gardening tools, trash bins. The exterior walkways are free from obstructions and debris.

LPA conducted resident and staff file reviews and interviews.

An exit interview was conducted with Gina Flores, whose signature on this form confirms receipt of these documents.

LPA is requesting the following documents be submitted to the Fresno CCL office by 6/28/24 Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610D) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond, updated facility sketch.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lissett Padgett	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

LIC809 (FAS) - (06/04)

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