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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880923
Report Date: 12/13/2023
Date Signed: 12/13/2023 02:54:22 PM

Document Has Been Signed on 12/13/2023 02:54 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
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:
12/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:LaTanya Clay, House ManagerTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to the facility to follow-up on incidents reported to the Regional Office on December 8, 2023. LPA met with LaTanya Clay, House Manager, and discussed the purpose of the visit.

During the visit, LPA conducted a health and safety check, conducted interviews, and obtained pertinent documents. No immediate health and safety concerns were observed.

An exit interview was conducted and a copy of this report was provided to House Manager Clay at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2023
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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