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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202729
Report Date: 09/25/2024
Date Signed: 09/25/2024 11:51:47 AM

Document Has Been Signed on 09/25/2024 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 HOMEFACILITY NUMBER:
435202729
ADMINISTRATOR/
DIRECTOR:		MURILLO, JENNIFERFACILITY TYPE:
737
ADDRESS:17390 SERENE DRIVETELEPHONE:
(831) 818-7981
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 4CENSUS: 3DATE:
09/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Jennifer MurilloTIME VISIT/
INSPECTION COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual required - 1 year inspection. LPA met with Administrator, Jennifer Murillo and Director of Operations, David Sandhu.

During visit, LPA toured the facility with staff to include the office, kitchen, living room, resident bedrooms, bathroom, 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 08/06/2024. Carbon monoxide observed present in the facility. Sprinkler system observed throughout the facility and last inspected in November 2023. Facility temperature maintained at 70 degrees Fahrenheit. LPA observed the facility has operable door alarms. 3 staff present are fingerprint cleared and associated to the facility.

Facility has at least 7 days worth of non-perishables and 2 days worth of perishable foods. Refrigerator temperature maintained at 36 degrees Fahrenheit. Freezer temperature in the kitchen initially maintained at 4 degrees Fahrenheit. LPA advised the freezer temperature should be maintained at 0 degrees Fahrenheit. Items inside the freezer observed cold and frozen. Items inside the refrigerator observed covered and labeled. Fruits and vegetables observed. The garage has another refrigerator temperature maintained at 35 degrees F.

LIC812-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2024
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: 09/25/2024
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Resident bedrooms observed with bedding, linens, dressers, and adequate lighting. Bathroom observed with non-slip mats in the shower. Bathroom shutter blinds next to the shower observed in disrepair as the middle part of the blinds that controls the shutters is removed. Blinds are able to close shut for privacy manually. ADM placed a work order for repair of the blinds during visit. Hot water temperature in the bathroom maintained at 110 degrees F.

3 residents files were reviewed. 3 out of 3 residents files contained an admission agreement, physician's report, TB result, updated IPP, personal rights form, and consent forms. 2 resident's file contained an admission agreement between the facility, consumer and San Andreas Regional Center. DOO states they have the admission agreement on paper but was not uploaded in their electronic file. LPA advised to ensure the admission agreement between the facility and resident is placed on file. DOO will email LPA the admission agreement. LPA was unable to reviewed 3 resident's safeguard of personal properties and valuables form as they were locked in a cabinet they were unable to access due to an incident with a resident. DOO will email LPA Dolores the safeguard of personal properties and valuables form once obtained. 3 resident's P&I money, centrally stored medication, and centrally stored medication records were inspected and observed maintained with no issues noted.

3 staff files were reviewed. 3 out of 3 staff files contained an updated 1st aid certification, LIC501, LIC503, and TB information. 3 staff are fingerprint cleared and associated to the facility. 3 staff has annual training to include 16 hours of emergency intervention. Staff are provided at least 20 hours of continuing education annually. Emergency drills are completed monthly. The last drill was completed on 09/02/2024 and 09/15/2024.

The Administrator's updated Administrator Certificate was obtained during visit to update the facility's file.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Jennifer Murillo and 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: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC809 (FAS) - (06/04)
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