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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700592
Report Date: 08/15/2022
Date Signed: 09/07/2022 08:42:11 AM


Document Has Been Signed on 09/07/2022 08:42 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, 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:
08/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:N/ATIME COMPLETED:
10:45 AM
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On 8/15/22 at approximately 10:00am Licensing Program Analyst (LPA) Maja Jensen arrived at the facility unannounced to conduct a required 1 year annual inspection. There was no one at the facility to meet with LPA.
LPA Jensen called Licensee on two phone numbers and sent email while at the facility and there was no response.

LPA Jensen observed the landscaping to be overgrown and various debris throughout the grounds. A Licensing Program Analyst will attempt to complete the inspection at a later date as access to the facility during the course of the visit.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2022
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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