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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202909
Report Date: 11/16/2023
Date Signed: 11/16/2023 10:58:24 AM

Document Has Been Signed on 11/16/2023 10:58 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 RESIDENTIAL CARE HOMEFACILITY NUMBER:
435202909
ADMINISTRATOR:QADDURA, MUNA AFACILITY TYPE:
735
ADDRESS:6071 EMLYN CT.TELEPHONE:
(408) 439-0857
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 4CENSUS: 0DATE:
11/16/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:John ManibusanTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Christine Dolores arrived announced to conduct the facility's pre-licensing inspection. LPA met with Licensee, John Manibusan and future Administrator, Avery Manibusan.

The facility has an approved fire clearance for 4 ambulatory residents. The facility has at least 2 fire extinguishers, smoke detectors, and carbon monoxides present in the facility. All exit areas were free and clear of obstruction.

The facility has a total of 4 private resident bedrooms each equipped with a bed, linens, dresser, night stand, lamp, ceiling light, closet, and a chair. The facility has 2 bathrooms each equipped with a toilet, shower, sink, garbage can, and lighting. The showers contains non-slid matts and grab bars. Bathroom hot water temperature located in the hallway is maintained at 118 degrees Fahrenheit.

The kitchen is equipped with plates, cups, bowls, utensils, and a lidded trash bin. LPA observed a drawer that contains a lock that is intended to store sharp objects. Chemicals and disinfectants observed stored in a locked cabinet located in the garage. Licensee was advised to ensure a lock will be placed if they plan to store chemicals and disinfectants underneath the kitchen sink. Licensee stated understanding. Kitchen refrigerator and freezer did not contain a thermometer. Licensee purchased a thermometer during visit. LPA advised the kitchen refrigerator should maintain a maximum temperature of 45 degrees Fahrenheit and freezer should maintain at 0 degrees Fahrenheit. LPA observed non-perishable foods in the cabinet. Facility has at least 7 days worth of non-perishables. SEE LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023
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 RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202909
VISIT DATE: 11/16/2023
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Dining rooms contains a table and chairs. The fireplace in the living room observed screened. The family room is intended to be used as a recreational area for the clients. The facility sketch indicates a staff room next to the family room. Based on interview with the Licensee, the room will be used as an office space. Licensee updated the facility sketch and provided a copy to LPA Dolores via email. The office space is equipped with locked cabinets and drawers for medical records and medications. Facility's first aid kit contains bandages, gauze, scissors, tweezers, and a manual. LPA advised to ensure the fire aid kit also contains a thermometer.

The garage observed with locked storage cabinets, a washer and dryer, and freezer. LPA advised to ensure the freezer contains a thermometer. Facility contains Personal Protective Equipment (PPE) supplies to include gowns, shields, gloves, masks, hand sanitizer, disinfectant wipes.

The facility's backyard observed with 2 exit areas which were free and clear of obstructions. The exit areas are not locked. LPA did not observe any open bodies of water. The backyard contains shade and a seating area. LPA observed a shed in the backyard that contained gardening items.

Posters observed near the entrance to include resident/client's personal rights, house rules, grievance and complaint information, and emergency disaster plan.

COMP III reviewed with Licensee, John Manibusan and future Administrator, Avery Manibusan.

No issues noted during this pre-licensing inspection. LPA observed the facility is ready to be licensed. However, this report will be submitted to the Central Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

This report was reviewed with Licensee, John Manibusan and future Administrator, Avery Manibusan and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC809 (FAS) - (06/04)
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