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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 02:45:01 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 - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Irene Nepomuceno, AdministratorTIME COMPLETED:
03:00 PM
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While at the facility conducting a Case Management inspection, Licensing Program Analyst (LPA) Praveen Singh conducted a Component III Orientation with Administrator Irene Nepomuceno and Licensee Kevin Broomfield per their request.

The Administrator and Licensee were provided with information to operate the facility within Title 22 regulatory compliance, as well as how to avoid common problem areas. Component III does not cover ALL regulations, only those found to be most problematic. Regulations require Administrator to be knowledgeable of all regulations and amendments to law.

Exit interview conducted and a 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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