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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002937
Report Date: 12/14/2022
Date Signed: 12/20/2022 01:45:52 PM


Document Has Been Signed on 12/20/2022 01:45 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:SERENITY HOME FOR SENIORFACILITY NUMBER:
315002937
ADMINISTRATOR:CADORNA, JULIUSFACILITY TYPE:
740
ADDRESS:5406 SAGE CTTELEPHONE:
(916) 203-6993
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:6CENSUS: 5DATE:
12/14/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Julius Cadorna, ApplicantTIME COMPLETED:
04:00 PM
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On 12/14/2022 LPA Tryon visited the facility to conduct a prelicensing visit at the facility. LPA met with applicant Julius Cadorna.
LPA and applicant reviewed the prelicensing section of the CARES Tool, did a tour of the entire facility including common areas, kitchen, dining area, living room, bedrooms, bathrooms, hallways, storage, garage area, yard.

The facility is clean and in good condition, nicely furnished. There is space for relaxation and activities, a small but nice back yard. Food and kitchen supplies are adequate to meet the needs of residents. Medications are locked in a special cupboard in the kitchen. Home appears safe, no hazards noted.

The home has appropriate paperwork and postings, fire extinguishers are charged and present, smoke detectors installed as well as carbon monoxide detector. Bedrooms are appropriately furnished.

At this time ,the home appears to be in substantial compliance with regulations. Fire clearance for 6 non-ambulatory residents.

LPA has waived Component III of the Orientation, as the new applicants have already been running another RCFE home in another community for at least 3 years and are familiar with regulations and processes.

No deficiencies were cited at this visit. Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
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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