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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202729
Report Date: 08/19/2022
Date Signed: 08/19/2022 10:55:57 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:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Jennifer MurilloTIME COMPLETED:
11:00 AM
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) Christine Dolores arrived unannounced to conduct the facility's annual inspection to focus on infection control. LPA let with Program Administrator, Jennifer Murillo. All staff observed to be wearing a face mask.

LPA observed the central entry point to include posters such as symptoms of COVID, droplet precaution, visitor guidelines, and stop the spread of germs. Staff conducted a temperature check at entry and verbally asked for all signs and symptoms of COVID-19. Staff screen for symptoms of COVID prior to starting their shift using a QR code. Hand sanitizer available. Bathrooms supplies with hygiene products, paper supplies, and hand washing sign. Staff clean and disinfect multiple times daily and as needed. LPA observed facility's Personal Protective Equipment (PPE) supplies. Clients are being monitored for symptoms multiple times daily and frequently, if needed. Staff are N95 fit-tested.

LPA reviewed facility's procedures to training, isolation, visitation, and testing requirements.

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)
Page: 1 of 1