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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880679
Report Date: 04/05/2022
Date Signed: 04/13/2022 04:47:01 PM


Document Has Been Signed on 04/13/2022 04:47 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:SERENITY SPRINGSFACILITY NUMBER:
331880679
ADMINISTRATOR:NORTH, ARIELFACILITY TYPE:
740
ADDRESS:9850 BOLTON AVETELEPHONE:
(213) 321-4285
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY:6CENSUS: DATE:
04/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:TIME COMPLETED:
10:40 AM
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LPAs Tricia Danielson and Chinwe Nwogene arrived unannounced to the facility to conduct an annual inspection. LPAs rang the RING doorbell and knocked several times but were unable to make contact with anyone in the facility. LPAs observed several vehicles in the driveway as well. LPA Danielson phoned Licensee/Administrator Ariel North to request a representative return to the facility to facilitate LPA's visit. North stated she was not going to return to the facility as requested. LPA provided consultation regarding licensing requirements and also informed North up the facility's unpaid annual fees. North requested that LPA send her an email reiterating all the information provided. LPAs vacated the premises.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022
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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