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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002937
Report Date: 09/20/2023
Date Signed: 09/20/2023 03:01:56 PM


Document Has Been Signed on 09/20/2023 03:01 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 6DATE:
09/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Belen Francisco, StaffTIME COMPLETED:
12:30 PM
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Licensing Program Analysts (LPA) John Todd Tryon conducted an unannounced case management visit on 09/20/2023. This visit is to confirm ORDERS TO INDIVIDUAL FOR IMMEDIATE EXCLUSION FROM ALL FACILITIES.

LPA met with caregiver Belen Francisco and stated the purpose of visit. LPA spoke with Administrator Julius Cadorna by phone. Facility understands this is an Immediate Exclusion effective 09/20/2023 and S1 is excluded and cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services. Therefore, the Department orders the facility to remove S1 from any contact with clients and not allow this employee to be physically present in the facility.

Exit interview conducted, a copy of this report provided on this date. A signature on these forms acknowledges receipt of these forms.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023
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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