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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700696
Report Date: 08/16/2021
Date Signed: 08/16/2021 02:44:18 PM

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:
08/16/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Irene Nepomuceno, AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Praveen Singh arrived to conduct an unannounced Case Management inspection to verify information related to Hospice Waiver Request. LPA met with Administrator Irene Nepomuceno and discussed the purpose of the visit. Prior to initiating the inspection, LPA 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 Facility Representative and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

During the inspection, LPA toured the interior of the facility including but are not limited to: common areas, resident bedrooms, bathrooms, kitchen and laundry area. In the areas toured no immediate health, safety, or personal rights violations were observed. The facility is clean, safe and sanitary. LPA verified that the facility is currently vacant and free of any tenants.

Facility is found to be in substantial compliance at this time. No deficiencies cited during inspection. Exit interview conducted and copy of this report provided.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 236-4743
LICENSING EVALUATOR NAME: Praveen SinghTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2021
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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