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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202729
Report Date: 09/22/2021
Date Signed: 09/22/2021 11:48:25 AM

Document Has Been Signed on 09/22/2021 11:48 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:SERENITY HOMEFACILITY NUMBER:
435202729
ADMINISTRATOR:WINGO, JENNIFERFACILITY TYPE:
737
ADDRESS:17390 SERENE DRIVETELEPHONE:
(831) 818-7981
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 4CENSUS: 3DATE:
09/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Heidi Morgan and Jovana McGrawTIME COMPLETED:
12:00 PM
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Licensing Program Analysts (LPA) Christine Dolores and Licensing Program Manager (LPM) Jackie Jin conducted an unannounced annual required inspection. LPA and LPM met with CEO, Heidi Morgan and Behavioral Specialist, Jovana McGraw.

During today's visit LPA and LPM toured part of the facility, due to a resident de-escalation process from an incident that happened earlier in the morning. LPA and LPM discussed the facility's infection control plan.

LPA and LPM observed a central entry point, screening area, and hand sanitizer for all visitors and staff. LPA and LPM observed the bathroom to have supplies of paper towels and soap available for staff, residents, and visitors. Trash cans were observed covered with lid. LPA and LPM observed the following posters, symptom reporting, social distancing, and cough etiquette. Facility has a sufficient amount of PPE supplies. Facility disinfect and sanitize high touch surfaces daily and as needed. Facility has a mitigation plan in place to prevent the spread of COVID-19.

No deficiencies cited during today's visit per California Code of Regulations, Title 22.

This report was reviewed with Heidi Morgan, CEO. Copy of this report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2021
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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