<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202909
Report Date: 11/14/2024
Date Signed: 11/14/2024 03:53:25 PM

Document Has Been Signed on 11/14/2024 03:53 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:SERENITY RESIDENTIAL CARE HOMEFACILITY NUMBER:
435202909
ADMINISTRATOR/
DIRECTOR:		QADDURA, MUNA AFACILITY TYPE:
735
ADDRESS:6071 EMLYN CT.TELEPHONE:
(408) 439-0857
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 4CENSUS: 0DATE:
11/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Licensee, John ManibusanTIME VISIT/
INSPECTION COMPLETED:
04:00 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) Simi Rai conducted an unannounced Required 1 Year visit and met with Licensee, John Manibusan. This facility is vendorized by San Andreas Regional Center as level 4i to care for residents with developmental disabilities. LPA Rai did not observe staff or residents at the facility. This facility is currently non-operational.

LPA Rai observed the facility inside and outside. LPA Rai observed the exits were clear of obstruction. LPA Rai observed 1 shed which is being used as storage and not habitual space. LPA Rai observed 4 resident rooms, 1 staff room, living room, family room, dining room, kitchen and garage. LPA Rai observed food supply of 2 days of perishable foods and pantry space to keep 7 days of non-perishable foods. LPA Rai observed locked cabinets for chemicals, medications and sharp objects. LPA Rai measured the hot water temperature for 2 out of 2 bathrooms which read between 105.8 - 106.5 degrees Fahrenheit. Carbon monoxide detectors and smoke alarms are in working condition.

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

Licensee, John Manibusan agreed and understood to continue to pay the annual fee and facility cannot be rented out as the location is still a licensed facility. Licensee, John Manibusan agreed and understood that the facility is in active status, therefore, they are not exempted from adhering to Title 22, Division 6 Policy, Regulations, and Laws. LPA Rai advised Licensee, John Manibusan to inform the Community Care Licensing Regional Office when the first resident has been admitted to the facility.

No deficiencies were cited at this time as per California Code of Regulations, Title 22. This report was reviewed with Licensee, John Manibusan and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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 1