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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700592
Report Date: 10/27/2021
Date Signed: 10/27/2021 09:46:59 AM

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 HOME @ MCKINLEYFACILITY NUMBER:
392700592
ADMINISTRATOR:ENRIQUEZ, JAMES LUKEFACILITY TYPE:
740
ADDRESS:10350 S. MCKINLEY AVE.TELEPHONE:
(209) 888-4495
CITY:FRENCH CAMPSTATE: CAZIP CODE:
95231
CAPACITY:20CENSUS: 0DATE:
10/27/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:James Luke EnriquezTIME COMPLETED:
10:00 AM
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On 10/27/2021 at 9:20am, Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a case management visit to clear POC's cited during Required- 1 Year annual inspection. LPA met with Administrator and Licensee and was allowed entry into the facility, today's census is 0.

Observed POC for deficiency cited under Title 22 87303(a) has been completed by extended POC due date.

Observed POC for deficiency cited under Title 22 87203 has been completed and POC cleared prior to today's inspection.

POC letter generated and provided during today's visit.

Per the California Code of Regulations, Title 22, no deficiencies observed or cited. Exit interview held and a copy of report provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
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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