435202729-7-31-2026-26-AS-MMOR-DWHQ4U-20260731115056

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202729
Report Date: 07/31/2026
Date Signed: 07/31/2026 11:51:13 AM

Document Has Been Signed on 07/31/2026 11:51 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME:	SERENITY HOME		FACILITY NUMBER:	435202729
ADMINISTRATOR/ DIRECTOR:	MURILLO, JENNIFER		FACILITY TYPE:	737
ADDRESS:	17390 SERENE DRIVE		TELEPHONE:	(831) 818-7981
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY: 4		CENSUS: 3	DATE:	07/31/2026
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:15 AM
MET WITH:	Administrator Jennifer Murillo		TIME VISIT/ INSPECTION COMPLETED:	12:00 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	On July 31, 2026, Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management - incident visit regarding an incident report regarding resident R1. LPA met with Administrator Jennifer Murillo and explained the purpose of the visit. On July 13, 2026, the Department received an incident report (IR) regarding resident R1. The incident report stated, on July 12, 2026, at approximately 2:25 AM, R1 came out of his/her room to use the bathroom. Inside the bathroom, he/she locked the door then climb through the window, that was previously left open, outside. R1 went around the house through the side gate and out the street. He/she was walking with a flashlight by him/herself. R1 was found by Staff S1, who was on his/her way to Serenity House. S1 notified the home and stayed with R1. When staff arrived in the van to pick up R1 he/she initially refused to come back. R1 then said he/she didn’t want to get in “trouble.” Staff reassured R1 he/she’s safe and R1 got in the van with no further escalation and arrived at the house. On July 20, 2026, Licensing Program Analyst Manuel Monter interviewed staff S2 and S3. S2 stated the night of the elopement, R1 went to the bathroom around 1:40am-1:50am. S2 stated he/she was watching from the hallway and could see the bathroom door from where he/she was standing. S2 stated 10-15 minutes later, the house lead received a call, that R1 was found outside the home. S2 stated he/she heard R1 was found on Condit Street.

Romeo Manzano
Manuel Monter
	DATE: 07/31/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2026

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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Document Has Been Signed on 07/31/2026 11:51 AM - It Cannot Be Edited

Created By: Manuel Monter On 07/31/2026 at 11:24 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SERENITY HOME	FACILITY NUMBER: 435202729
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/31/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/01/2026 Section Cited CCR 80078(a)	1 2 3 4 5 6 7	80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidence by:	1 2 3 4 5 6 7	ADM stated she conducted a staff training for Leads and all staff on July 20 and 29, 2026, regarding the elopement incident and preventions. ADM stated she will submit to the Department documentation showing the training has taken place.
	8 9 10 11 12 13 14	Based on interviews conducted and records reviewed, resident R1 eloped from the facility unsupervised on July 12, 2026. This poses an immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:

	Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/31/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2026

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 HOME	FACILITY NUMBER: 435202729
	VISIT DATE: 07/31/2026

NARRATIVE

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The Department Reviewed resident R1’s Individual Program Plan (IPP) dated July 14, 2025. The IPP states, R1 can engage in choices that can be a danger to him/herself and others, and requires supervision at all times. Furthermore, the IPP states, R1 has a history of AWOL behaviors when he/she gets frustrated. R1 requires supervision both at home and in the community at all times, to ensure his/her health and safety and safety of others.

An immediate civil penalty of $500.00 is being assessed against the facility today for violation the absence of supervision, which resulted in R1 eloping from the facility unsupervised.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator Jennifer Murillo and a copy of the report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/31/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2026

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 HOME	FACILITY NUMBER: 435202729
	VISIT DATE: 07/31/2026

NARRATIVE

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S3 stated the night R1 eloped from the facility, around 1:40am, R1 had left his/her room and gone into the bathroom in the hallway. S3 stated 10-15 minutes after R1 entered the bathroom, the S1 informed the home that R1 was found outside the home. S3 stated the S1 told S3 to go pick up R1 with the company van. S3 stated R1 was found on Condit/East Main before the bridge. S3 stated R1 did not cross the bridge that is above the freeway.

Both Staff S2 and S3 stated R1’s exit seeking/eloping behavior is a known behavior. S2 stated the window where R1 had exited did not have an alarm before the elopement. S3 stated window in the bathroom did have an alarm but did not ring.

On July 21 and 28, 2026, Licensing Program Analyst Manuel Monter interviewed staff S1 and S4. S4 stated at approximately 2:00 AM he/she received a call from S1, informing him/her that R1 was outside the home. S4 stated he/she asked the other staff on shift about R1’s location. S4 stated the other staff informed him/her that they believed R1 was still in the bathroom. S4 stated he/she informed staff S2 and S3 that R1 had been found outside the home and instructed them to retrieve him. S4 stated that he/she, S2 and S3 were not aware that R1 had left the home unsupervised.

S1 stated he/she was just checking in with the other homes and seeing how the NOC shift staff and their leads were doing. S1 stated he/she had finished his/her visit at (Sycamore Home), and went on his/her way to tranquility home. S1 stated during his/her drive toward tranquility home he/she saw someone (R1) on the sidewalk. S1 stated he/she saw R1 near Serene/Laurel and east main. S1 stated R1 had not gone over the bridge. S1 stated he/she called the home and spoke to S4 and asked him/her to send a staff out with the van to bring R1. S1 stated the staff in the home were not aware that R1 had left the home.

S4 stated the bathroom window is equipped with an alarm, but he/she didn’t hear it activate. Staff S1 stated the bathroom window does have an alarm.

The Department reviewed resident R1’s Physician's Report, dated June 27, 2026. Based on a review, the physician’s report states R1 is not able to leave the facility unassisted.

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/31/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2026

LIC809 (FAS) - (06/04)

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