435202795-8-9-2026-26-AS-MPAA-DWT3DV-20260809181009

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202795
Report Date: 08/04/2026
Date Signed: 08/09/2026 06:24:44 PM

Document Has Been Signed on 08/09/2026 06:24 PM - 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:	SERENITAS CARE, LLC		FACILITY NUMBER:	435202795
ADMINISTRATOR/ DIRECTOR:	ZARRAGA, ANN MARIE		FACILITY TYPE:	740
ADDRESS:	677 SHAWNEE LANE		TELEPHONE:	(408) 677-3635
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY: 6		CENSUS: 6	DATE:	08/04/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:32 AM
MET WITH:	Ann Marie Zarraga		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

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) Maria (Mita) Partoza conducted an unannounced 1-year required inspection visit. The purpose of this visit was to ensure the licensee’s continued compliance with California Code of Regulations (CCR), Title 22, Division 6. LPA met with the Facility Administrator (ADM) Ann Marie Zarraga. The facility is currently licensed for a 6-bed capacity and has a current census of six (6) ambulatory only residents who have developmental disability at level 5. LPA observed 1 resident at the facility and is not able to verbally communicate clearly. LPA Partoza, inspected the facility inside and outside, including but not limited to the exterior perimeter, walkways, backyard, kitchen, dining, 2 bathrooms, 3 residents' room, 1 staff room, living area and garage. LPA observed the kitchen and dining area was sanitary and organized, knives were locked and not accessible to residents in care without supervision. The medication are in a secured locked cabinet. LPA observed 2 days of perishable food items, and 7 days of non-perishable items in the refrigerator and pantry. LPA inspected 3 resident bedroom, 3 out of 3 bedroom are shared and has sufficient storage (closet and chest drawers) to store the resident's personal belongings. 2 out of 2 bathrooms were inspected, and bathrooms have grab bars and non-skid mats. LPA measured the water temperature for kitchen, and 2 bathroom and temperature ranges from 116.7 degree F in the bathroom and 123 degree F for the kitchen. LPA observed a warning sign in front of the kitchen sink stating "caution water temperature exceeds 125 degree F." page 1 of 3

Romeo Manzano
Maria Partoza
	DATE: 08/04/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2026

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 5

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 of 5

Document Has Been Signed on 08/09/2026 06:24 PM - It Cannot Be Edited

Created By: Maria Partoza On 08/04/2026 at 03:37 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SERENITAS CARE, LLC	FACILITY NUMBER: 435202795
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87612(a)(5)

87612 Restricted Health Conditions (a) The licensee may provide care for residents who have any of the following restricted health conditions, or who require any of the following health services: (5)Diabetes as specified in Section 87628. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interviews on 08/04/2026, the licensee did not obtain a Department exception before staff provided restricted care to R3 and R1. Staff began daily glucose testing on 09/09/24 & restarted on 10/15/25. S2 & S3 stated they perform finger pricks and operate the monitor. Per PIN 17-09-ASC, staff device manipulation constitutes administration, not self-testing, which pose/s a potential health, safety and personal right risk to persons in care.
	POC Due Date: 08/18/2026
	Plan of Correction
1 2 3 4	ADM stated he/she shall submit a complete Restricted Health Condition Exception packet for diabetes (Title 22 CCR § 87612(a)(5)) PA by 08/18/2026. The packets will include physician orders, specific high/low response protocols, and signed staff training logs proving monitor competency. Any restricted health tasks will not be initiated without prior Department approval.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:

	Maria Partoza
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/04/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2026

LIC809 (FAS) - (06/04)

Page: 5 of 5

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: SERENITAS CARE, LLC	FACILITY NUMBER: 435202795
	VISIT DATE: 08/04/2026

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
26
27
28
29
30
31
32

Based on record review and interviews conducted with three out of three (3 of 3) facility staff who were currently on duty at the time of the visit. 3 out of 3 staff confirmed that facility staff are the individuals physically executing the daily health monitoring tests for both R3 and R2.

S2 and S3 stated that they perform the finger pricks, load the testing strips, and physically press the operational buttons on the testing devices. S3 demonstrated how the lancet device is used. S1 stated due to R3s behavior of grabbing and throwing, the staff are the ones who administer the glucose test on R3. S1 stated that R1 has difficulty with his/her fine motor skill and makes make administering testing device of R1 to difficult to perform independently even with the hand over hand assistance.

Per Department Provider Information Notice (PIN) 17-09-ASC, active physical execution or device manipulation of a health testing device by facility staff constitutes care administration rather than resident self-testing. Based on record review the facility staff are actively administering a restricted health task. The facility did not secure an exceptions for R3 and R2 for restricted health conditions under California Code of Regulations

87612 Restricted Health Conditions (a) The licensee may provide care for residents who have any of the following restricted health conditions, or who require any of the following health services: (5)Diabetes as specified in Section 87628.

During today's visit deficiencies are cited under Title 22 CCR 87612(a)(5). see LIC 809D.
An exit interview was conducted with administrator Ann Marie Zarraga and a copy of the report and appeals rights was provided.

end of report
page 3 of 3

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/04/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2026

LIC809 (FAS) - (06/04)

Page: 4 of 5

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: SERENITAS CARE, LLC	FACILITY NUMBER: 435202795
	VISIT DATE: 08/04/2026

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
26
27
28
29
30
31
32

LPA observed, that walkways, hallways and exit doors are free from obstructions. LPA reviewed 3 resident record and 3 staff records including but not limited to physician's report, appraisal needs and services plan, centrally stored medication record (CSMDR), medication administration record (MAR), personal and incidental. LPA observed that staff have updated certificates for 1st aid/CPR training, direct support staff training and in-service training including fire and earthquake drills. The facility is equipped with fire extinguishers, smoke and carbon monoxide alarms that are operational.

Based on record review conducted, the facility currently provides care and supervision to two (2) residents who are consumers of a placement agency with a Level 5 care designation.

Resident #3 (R3) is under 60 years of age. A review of R3's file and logged tracking charts reveals that staff administered health monitoring using a sharp lancet device was originally initiated on 09/09/2024 once daily. A review of logged tracking charts indicates this staff administered the routine test that restarted on 10/15/2025 once daily following a documented shift in clinical tracking data. Documentation shows facility staff completed related operational training on 08/15/2025. A review of the facility's file revealed the licensee does not have a record for under age exception and for restricted health condition exception from the Department for R3.

Resident #2 (R2). R2 is a senior resident. A review of R2's file and logged tracking charts stated that staff administered health monitoring using a sharp lancet device is continuously administered since 2021 once daily. Documentation shows facility staff completed related operational device training on 09/15/2025 for R2. Based on record review no staff training documentation existed prior to 09/15/2025 for R2. Based on record review the licensee did not have a Restricted Health Condition Exception from the Department for R2.

page 2 of 3

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/04/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2026

LIC809 (FAS) - (06/04)

Page: 3 of 5