<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003477
Report Date: 05/10/2022
Date Signed: 05/10/2022 05:55:26 PM

Document Has Been Signed on 05/10/2022 05:55 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SERENITY FAMILY CARE HOMEFACILITY NUMBER:
347003477
ADMINISTRATOR:VILLANUEVA, MARIA TERESA MFACILITY TYPE:
740
ADDRESS:9086 PIAZZA COURTTELEPHONE:
(916) 681-8630
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 4CENSUS: 3DATE:
05/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
05:10 PM
MET WITH:Noli VillanuevaTIME COMPLETED:
06:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to conduct an annual inspection. LPA Valerio was met by facility staff/Co-Administrator Noli Villanueva and explained the purpose of the visit.

LPA Valerio completed the infection control tool during the visit. The facility has the necessary COVID, hand-washing, and social distancing guidelines posted at the front door of the facility. LPA observed the sign in sheet for visitors at the front door. The sign in sheet had necessary questions and are stored in a binder in the front. The facility was observed to be clean and organized during the time of visit. Facility staff were observed to be wearing mask throughout the visit. The facility has a air purifying system in the home

LPA toured the facility inside and out to ensure compliance of Title 22 regulations. All emergency exits were clear from obstructions. The medication cabinet, sharps, and cleaning supplies were locked and inaccessible to residents in care. Hot water was measured at 116.3*F degrees, which is within regulatory range. Temperature inside the home read 72*F. All required furniture and furnishings were observed in the resident bedrooms and bathrooms. Resident rooms were clean, organized, and had zero odors. Fire extinguishers were observed to be charged and within compliance with last check on 01/26/2022.

LPA observed 3 residents in care. Residents were observed in the living room watching television, sleeping in their rooms, and watching television in the bedroom. No documentation was requested during this visit since Administrator provided documentation during previous annual on 02/10/2022.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report was left at the facility with Facility Staff/ Co-Administrator Noli Villanueva. Administrator Maria was notified via phone of the visit.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1