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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003297
Report Date: 07/27/2023
Date Signed: 07/27/2023 03:41:07 PM


Document Has Been Signed on 07/27/2023 03:41 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:LA SERENA HOUSEFACILITY NUMBER:
347003297
ADMINISTRATOR:VILLAROSA, MARIBELFACILITY TYPE:
740
ADDRESS:8970 LA SERENA DRIVETELEPHONE:
(916) 966-0865
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 6DATE:
07/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Aida Briones, LicenseeTIME COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 7/27/23 to conduct a Required-1 Year Inspection utilizing the inspection tool.

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are four (4) bedrooms and two (2) bathrooms for resident use. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 117.5 degrees F.

LPA checked the kitchen area for the ability to prepare and store food. Care home has required two (2) day perishable and seven (7) day non-perishable food supply on cite. LPA observed knives, cleaning products, and other toxins to be locked away and inaccessible to residents. LPA observed the backyard and perimeter of the care home to be free of clutter and debris. LPA observed smoke detectors and carbon monoxide detectors to be operational in the care home. First aid kit is maintained and ready for emergency use.

LPA checked medication storage and found medication to be locked away and inaccessible to the residents. LPA reviewed three (3) resident files and three (3) staff files. Facility has a current copy of certificate of liability insurance and LPA obtained a copy.

As a result of today's visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview was conducted and copy of the report was given to the care home at the conclusion of today's visit.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
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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