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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202729
Report Date: 10/13/2023
Date Signed: 10/16/2023 08:25:30 AM

Document Has Been Signed on 10/16/2023 08:25 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: 3DATE:
10/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:David SandhuTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's Required 1 Year inspection. LPA met with Director of Operations, David Sandhu.

During visit, LPA toured the facility with staff to include the office, activity room, kitchen, living room, resident bedrooms, bathrooms, laundry room, garage, and backyard. All fire exit routes were free and clear of obstruction. All sharp objects, cleaning solutions, disinfectants, and medications observed locked. Fire extinguisher last serviced on 08/08/2023. Carbon monoxide observed present in the facility. Sprinkler system observed throughout the facility and last inspected in April 2023. Facility temperature maintained at 71 degrees Fahrenheit. LPA observed a bin filled with PPE supplies.

Resident bedrooms observed with bedding, linens, dressers, and lighting. Facility has at least 7 days worth of non-perishables and 2 days worth of perishable foods. Refrigerator temperature maintained at 35 degrees Fahrenheit. Freezer temperature in the kitchen initially maintained at 5 degrees Fahrenheit. Staff immediately lowered the freezer temperature to 0 degrees Fahrenheit. The garage has another refrigerator and freezer which LPA was unable to check on the temperature due to technical difficulties. LPA observed the refrigerator felt warmer than average. Staff brought the items into the kitchen refrigerator.

LPA observed the facility's emergency supply. Hot water temperature in the bathroom maintained at 114 degrees Fahrenheit.

LPA observed the facility's transportation vehicle that was parked on the driveway. The transportation vehicle's registration is up to date. Vehicle is supplied with PPE supplies and first aid kit. SEE LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2023
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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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: 10/13/2023
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3 residents files (R1 - R3) were reviewed. 3 out of 3 residents files contained an admission agreement, medical assessment, TB result, updated IPP and IBSPs, personal rights form, consent forms, and safeguard of personal property and valuables form. R1 - R3's P&I money, centrally stored medication, and centrally stored medication records were inspected. LPA advised to ensure each medication start dates were accurate.

3 staff files (S1 - S3) were reviewed. 3 out of 3 staff files contained an updated 1st aid certification, fingerprint clearance, LIC501, LIC503, TB information, and LIC9052. S1 - S3's annual training were reviewed to include 16 hours of emergency intervention and infection control. Staff are provided at least 20 hours of continuing education annually. Facility conducts emergency drill at least quarterly with all staff per shift.

LPA reviewed the facility's' infection control plan, emergency disaster plan, and facility file. Posters observed in the facility to include COVID-19 related posters, evacuation plan, and personal rights form.

During visit, LPA obtained a copy of the facility's emergency disaster plan.

No deficiencies were cited per California Code of Regulations, Title 22. Advisory note provided. This report was reviewed with Director of Operations, David Sandhu and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023
LIC809 (FAS) - (06/04)
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