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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202729
Report Date: 08/19/2022
Date Signed: 08/19/2022 10:55:38 AM

Document Has Been Signed on 08/19/2022 10:55 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 HOMEFACILITY NUMBER:
435202729
ADMINISTRATOR:MURILLO, JENNIFERFACILITY TYPE:
737
ADDRESS:17390 SERENE DRIVETELEPHONE:
(831) 818-7981
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 4CENSUS: 2DATE:
08/19/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Jennifer MurilloTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management visit and met with Program Administrator, Jennifer Murillo . The purpose of the visit was to follow-up on an incident report the Department received regarding resident (R1) and staff (S1).

During a series of conversations between R1 and S1, it was disclosed that S1 became verbally aggressive to R1.

The facility’s staff immediately followed-up after learning about the incident and interviewed staff, S1 – S3 and R1. After conducting an internal investigation, S1 was terminated from all the EBSI homes.

Licensee has conducted virtual training for staff with the facility's behaviorist on how to respond to clients professionally and suggested alternatives when exhibiting behaviors. Licensee will conduct an all-staff training on personal rights and remind staff on their personnel policy on violating client’s personal rights. Licensee will submit their proof of both training with trainers information, date of training, and attendance sheet to LPA by 08/31/2022.

No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed with Program Administrator, Jennifer Murillo and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2022
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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