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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202909
Report Date: 09/14/2023
Date Signed: 09/14/2023 10:38:52 AM

Document Has Been Signed on 09/14/2023 10:38 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
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:SERENITY RESIDENTIAL CARE HOMEFACILITY NUMBER:
435202909
ADMINISTRATOR:QUADDURA, MUNA AFACILITY TYPE:
735
ADDRESS:6071 EMLYN CT.TELEPHONE:
(408) 439-0857
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 4CENSUS: DATE:
09/14/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:John Manibusan, Managing Member; Muna Ali Qaddura, AdministratorTIME COMPLETED:
10:23 AM
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Facility Type: ARF
Application Type: Initial
Capacity: 4
COMP II Participants: John Manibusan, Managing Member; Muna Ali Qaddura, Administrator
Interview Method: Telephone interview

On 9/14/23, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Mirella Quaranta
LICENSING EVALUATOR NAME: Anna Barrios
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2023
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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