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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002937
Report Date: 10/04/2023
Date Signed: 10/04/2023 10:13:21 AM


Document Has Been Signed on 10/04/2023 10:13 AM - 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



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:
10/04/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Belen Francisco, CaregiverTIME COMPLETED:
10:20 AM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a collateral visit. LPA met with caregiver during today's visit.

LPA arrived today to interview resident concerning an issue that was not related to this facility.

In the areas that were evaluated, no deficiencies were observed at the time of the visit.

Exit Interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023
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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