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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201883
Report Date: 07/28/2021
Date Signed: 07/29/2021 02:13:39 PM

Document Has Been Signed on 07/29/2021 02:13 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:SERENITY CARE HOME RCFEFACILITY NUMBER:
435201883
ADMINISTRATOR:MELBURGA SENOTFACILITY TYPE:
740
ADDRESS:684 LAKEWOOD DRTELEPHONE:
(408) 747-3439
CITY:SUNNYVALESTATE: CAZIP CODE:
94089
CAPACITY: 6CENSUS: 5DATE:
07/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Alma Amistad and Violet MariTIME COMPLETED:
11:05 AM
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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced infection control site visit today. LPA met with the Caregivers-in-Charge Alma Amistad and Violet Mari.

One central entry point was designated for all staff, residents, and visitors. A temperature screening station, sign in sheet, and hand sanitizer were present at the entrance.

LPA toured the facility. The facility was observed to be in sanitary condition. COVID-19 signs were posted at the entrance and living room.

LPA inspected the residents' restroom. The restroom was observed to be adequately stocked with paper towels and hand soap.

Facility was observed to have a sufficient supply of PPE in the storage area. LPA discussed the infection control with Caregivers-in-Charge, suggestions were given. 5 residents and 2 on duty staff were fully vaccinated per Caregivers-in-Charge.

No deficiency cited during visit. However, advisory notes (LIC 9102) were issued.

This report was reviewed with the Caregivers-in-Charge. A copy of this report and advisory notes were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Yatfai Ng
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2021
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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