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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202456
Report Date: 12/06/2021
Date Signed: 12/06/2021 03:50:11 PM

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 OF SILICON VALLEYFACILITY NUMBER:
435202456
ADMINISTRATOR:RITA GARCIAFACILITY TYPE:
740
ADDRESS:777 TERRAZZO DRIVETELEPHONE:
(408) 972-0125
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:6CENSUS: 6DATE:
12/06/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Rita GarciaTIME COMPLETED:
02:59 PM
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
Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection, and met with administrator (ADM) Rita Garcia and Licensee (LNS) Thuc Oanh Trinh. Upon arrival staff Erlinda Agbuya (EA) took LPA body temperature and logged LPA in guest book. EA did not ask the infection control questionnaires.

LPA toured the facility inside out with ADM. Two resident shared rooms, two resident single rooms, and one staff live-in room were observed. The beds in shared room were observed 6 feet apart. Kitchen, living room, dinning room and two restrooms were inspected. Not all trash cans were with covers. ADM stated the facility will fix it in 3 days. No paper towels with holders were observed in kitchen and dinning room. ADM stated the facility will fix it in one day. Two day perishable food supplies and seven nonperishable food supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was observed at 70 degree F, and hot water temperature was observed 105 degree F. PPE supplies were observed less 30 days supplies, but LNS showed LPA the PPE supplies in LNS's office at next door facility for 3 facilities. The PPE supplies were observed sufficient for 30 days for 3 facilities.

Fire extinguisher was serviced on 07/20/2021. The facility was equipped with smoke and carbon monoxide detectors, and fire alarm. Front yard and backyard were inspected. There was no obstruction observed to block the walkways. ADM stated all the staff and residents are fully vaccinated. ADM stated all staff and residents except one resident have the booster shots.

No deficiency or citation were noted today. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of this report was emailed to ADM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021
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