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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700696
Report Date: 05/12/2021
Date Signed: 05/13/2021 06:22:18 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:MOUNT HOOD SERENITY CAREFACILITY NUMBER:
342700696
ADMINISTRATOR:NEPOMUCENO, IRENEFACILITY TYPE:
740
ADDRESS:5704 MOUNT HOOD COURTTELEPHONE:
(916) 993-6894
CITY:SACRAMENTOSTATE: CAZIP CODE:
95842
CAPACITY:6CENSUS: 0DATE:
05/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:32 PM
MET WITH:IRENE NEPOMUCENOTIME COMPLETED:
04:15 PM
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Licensing Program Analysts (LPAs) Konnor Leitzell and Danyle Wolter arrived at the facility to conduct the facilities Required-1 Year Inspection utilizing the infection control domain, LPAs met with Irene Nepomuceno (Admin) and explained the purpose of the visit. Prior to initiating the annual inspection, LPAs completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks.

Prior to the visit, LPAs were informed that no residents were in care. During the visit, LPAs toured the facility and noted there were no residents in care. Admin informed LPAs that facility will notify Community Care Licensing (CCL) upon them retaining their first residents. LPAs completed the Inspection tool during the visit, indicating N/A for all sections due to no residents being in care.

LPAs conducted exit interview with admin, and provided a printed copy of the signed report. No deficiencies cited during today's visit.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor LeitzellTELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021
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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