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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880923
Report Date: 09/11/2023
Date Signed: 09/11/2023 02:25:36 PM

Document Has Been Signed on 09/11/2023 02:25 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,
, CA
FACILITY NAME:SERENITY ADULT CARE HOMES, IIIFACILITY NUMBER:
361880923
ADMINISTRATOR:SIMPSON, DARLEENEFACILITY TYPE:
735
ADDRESS:14995 HUNTINGTON STTELEPHONE:
(714) 225-2482
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY: 4CENSUS: 4DATE:
09/11/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Pebbles Nakielski, AdministratorTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct a collateral visit to interview Client #1 (C1) related to an investigation regarding CC #18-AS-20210806131118 which concerns another facility.

Today's visit LPA spoke with Administrator Pebble Nakielski and informed her of the purpose of today's visit. Nakielski reported C1 no longer resides at the home. C1 moved from the home on August 30, 2023 and moved in with family.

There were no deficiencies cited during today's visit. An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names list.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2023
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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