<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601183
Report Date: 10/25/2024
Date Signed: 10/25/2024 09:18:42 AM

Document Has Been Signed on 10/25/2024 09:18 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 BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:SERENE HAVEN HOMEFACILITY NUMBER:
415601183
ADMINISTRATOR/
DIRECTOR:		FAJARDO, BILL DANHELFACILITY TYPE:
735
ADDRESS:2530 WENTWORTH DRTELEPHONE:
(650) 267-9482
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 4CENSUS: 0DATE:
10/25/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:31 AM
MET WITH:Claire Ascalon & Bill FajardoTIME VISIT/
INSPECTION COMPLETED:
09:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 8/15/24, Licensing Program Analyst (LPA) Grace Donato conducted an announced Pre-Licensing Inspection visit. LPA met with Administrator, Bill Fajardo & Claire Ascalon.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. LPA observed the indoor and the outdoor passageways are free of obstruction. Facility is single level with 4 rooms. All rooms are observed with required furniture and lighting, bathrooms are odor-free and in good repair and have grab bars. Emergency food supply is observed.

Facility lighting is sufficient for comfort and safety. LPA toured the kitchen area and observed it to be clean. Facility refrigerator & freezer temperatures are within regulatory standards. Chemicals & sharps have their own locked storage in the garage. All fire prevention systems such as smoke detectors, carbon monoxide detector, fire extinguishers have been inspected in place.

Component III is also conducted on this day.

Facility is clean and in good repair based on observations made today. Facility is in compliance with Title 22 regulations. No citations are issued.

A copy of report is provided.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1