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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201883
Report Date: 07/27/2022
Date Signed: 07/27/2022 12:18:14 PM


Document Has Been Signed on 07/27/2022 12:18 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
CENTRAL COAST CR/RES, 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: 6DATE:
07/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:18 AM
MET WITH:Josephine CalibosoTIME COMPLETED:
12:25 PM
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On 07/27/2022, Licensing Program Analyst (LPA) Mandeep Kaur conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit . LPA met with the Caregiver-In-Charge Josephine Caliboso

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

LPA toured the facility inside and outside. Sharp objects, toxins, cleaning supplies are secured. Medications are stored in a locked cabinet in the kitchen.
The kitchen was inspected. There was sufficient perishable food for at least 2 days and nonperishable food for at least one week.

LPA inspected the residents' restrooms. The restrooms were observed to be adequately stocked with paper towels and hand soap.
Foot operated trash containers observed in the bathrooms and in the kitchen.

Facility was observed to have a sufficient supply of PPE in the storage area. LPA discussed the infection control with Administrator Melburga Senot over the phone and with the caregiver-in-charge.

Administrator Melburga Senot joined LPA later on.

No citations were issued per the California Code of Regulations Title 22.

This report was reviewed with the Administrator Melburga Senot . A copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Mandeep KaurTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022
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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