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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800059
Report Date: 01/12/2023
Date Signed: 01/12/2023 10:50:56 AM

Document Has Been Signed on 01/12/2023 10:50 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:SERENITY ADULT CARE HOMES IIFACILITY NUMBER:
361800059
ADMINISTRATOR:BOYCE, DARLEENEFACILITY TYPE:
735
ADDRESS:14534 HANDSDALE STREETTELEPHONE:
(714) 225-2482
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY: 6CENSUS: 3DATE:
01/12/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:06 AM
MET WITH:Darleene Simpson, LicenseeTIME COMPLETED:
10:55 AM
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On 01/12/2023, at 10:06 a.m., Licensing Program Analysts (LPAs) Rayshaun Nickolas and Magda Malcore made an unannounced visit to the facility to obtain signatures on amended LIC 9099s. LPA met with Darleene SImpson and explained the purpose of the visit.

An exit interview was conducted and a copy of this report and amended LIC 9099s were provided to Simpson.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2023
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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