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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003477
Report Date: 04/27/2023
Date Signed: 05/02/2023 10:56:06 AM


Document Has Been Signed on 05/02/2023 10:56 AM - 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:
04/27/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:36 PM
MET WITH:M. VillanuevaTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived Unannounced for a case management inspection. There are 2 residents in care.

LPA toured the interior and exterior of the facility including the common areas, bathrooms, residents room and garage. LPA observed the smoke/monoxide alarms to be in working order, and the fire extinguisher to have been serviced.

The purpose of the visit was to confirm that the service plans and 602 were updated according to the advisory. Licensee is waiting for the doctor to return the 602.

LPA will return at a later date to confirm the updated information.


Exit interview
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023
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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