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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920134
Report Date: 09/26/2024
Date Signed: 09/26/2024 03:03:43 PM


Document Has Been Signed on 09/26/2024 03:03 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:SERENE RESIDENTIAL LIVINGFACILITY NUMBER:
345920134
ADMINISTRATOR:SEGUBAN, LIZAFACILITY TYPE:
740
ADDRESS:7125 BRAYTON AVETELEPHONE:
(530) 409-9297
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:6CENSUS: 0DATE:
09/26/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Applicant- Cathy MarvosTIME COMPLETED:
03:05 PM
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On 09/26/24 Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Graham Gunby arrived at the facility announced and met with Applicant Cathy Marvos to conduct a Pre-licensing visit. The facility has an approved fire clearance for six (6) non ambulatory residents.

During today's inspection, LPAs and Applicant conducted a tour of the interior and exterior of the facility to ensure there is no immediate health, safety and personal rights violation. LPAs conducted a tour of three (3) shared bedrooms, two (2) bathroom, laundry room, kitchen, garage, backyard, and common areas. LPAs observed resident bedrooms to have the proper furniture. LPAs observed the facility to have a proper storage for medications, toxins and sharps which is locked and inaccessible. LPAs observed facility to have ample supply of personal hygiene, linen, and non-perishable foods. LPAs observed the exterior of the facility to be free of obstruction. LPAs observed the facility to have the required posters of Community Care Licensing. LPAs observed fire extinguisher serviced on 8/20/24. The temperature in the facility was 73 degrees Fahrenheit during the time of visit

LPAs and Applicant completed the inspection tool and Comp III. Pre-Licensing completed and no deficiencies was observed. LPAs will forward findings to the Centralized Application Bureau (CAB) that facility met all the pre-licensing components. Applicant has satisfied all requirements in accordance to Title 22, California Code of Regulations on today's pre-licensing inspection.

Exit interview conducted a copy of the report was left at the facility.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024
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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