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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202909
Report Date: 12/10/2024
Date Signed: 12/10/2024 04:50:52 PM

Document Has Been Signed on 12/10/2024 04:50 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: 2DATE:
12/10/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Administrator, Avery ManibusanTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit to follow up on a Incident Report received by the Department regarding resident (R1) who has not returned to the facility since 12/4/2024. LPA Rai met with Administrator (ADM) Avery Manibusan and stated the purpose of today's visit. LPA Rai observed 2 staff and 1 resident (R2) as 1 resident (R1) has not returned to the facility.

On 12/6/2024, the Department received Special Incident Report (SIR) for incident occurred on 12/4/2024. On 12/4/2024 at approximately 9:19pm, R1 signed out of the facility log to visit friend and stated R1 would return to the facility at 11pm. R1 did not return to the facility.

On 12/9/2024, the Department received an updated Special Incident Report (SIR) which stated R1's whereabouts remain unknown. On 12/9/2024, the Department interviewed Licensee, John Manibusan.

During today's visit, LPA Rai interviewed (ADM) Avery Manibusan. ADM was informed during today's visit of R1 was involved in an altercation wherein a high school student was alleged assaulted by R1. ADM stated to work with R1’s social worker, San Andreas Regional Center (SARC) and Licensing to provide updates on R1.
LPA Rai obtained copies of R1's records to include but not limited to R1's Admission Agreement, R1's Pre-Placement Appraisal and R1's Individual Program Plan.

LPA Rai determined this case management needs further investigation.

This report was reviewed with Administrator (ADM) Avery Manibusan and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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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