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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800059
Report Date: 12/11/2024
Date Signed: 12/11/2024 11:05:15 AM

Document Has Been Signed on 12/11/2024 11:05 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SERENITY ADULT CARE HOMES IIFACILITY NUMBER:
361800059
ADMINISTRATOR/
DIRECTOR:		BOYCE, DARLEENEFACILITY TYPE:
735
ADDRESS:14534 HANDSDALE STREETTELEPHONE:
(714) 225-2482
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY: 6CENSUS: 3DATE:
12/11/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Shamieka Leachman-House ManagerTIME VISIT/
INSPECTION COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced to conduct a Case Management Visit for health and safety. This case management visit is in response to a Special Incident Report (SIR) submitted to the Community Care Licensing Office. LPA was greeted by Staff, Natividad Saucedo at the front door. LPA introduced self and stated purpose of the visit.

During today's visit, LPA discussed the incident and surrounding events with House Manager, Shamieka Leachman. LPA did a health and safety check and reviewed client records.

No deficiencies were observed during this visit. An exit interview was conducted where this report was, reviewed, discussed and then provided to Shamieka Leachman.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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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