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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202909
Report Date: 12/26/2024
Date Signed: 12/31/2024 08:48:51 AM

Document Has Been Signed on 12/31/2024 08:48 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/
DIRECTOR:		QADDURA, MUNA AFACILITY TYPE:
735
ADDRESS:6071 EMLYN CT.TELEPHONE:
(408) 439-0857
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 4CENSUS: 2DATE:
12/26/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Administrator (ADM) Avery ManibusanTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit to follow up on visit conducted on 12/10/2024. LPA Rai met with Administrator (ADM) Avery Manibusan and Licensee (LIC) John Manibusan and stated the purpose of today's visit. LPA Rai observed 2 staff and 0 residents.

On 12/26/2024, LPA Rai followed up with ADM and LIC. LIC stated on 12/24/2024, R1 left the facility to walk to high school. LIC had left the facility around 10am since both residents were attending school and day program. When LIC returned to the facility around 1pm, R1 had entered the facility through a bathroom window and taken the facility van keys from the lockbox and drove off from the facility with the facility van. LIC stated R1 returned the facility van later in the day and left the facility again without informing LIC and ADM.

This was the second incident where R1 returned the facility and entered the facility when staff were not present at the facility. LIC stated he has scheduled a staff to be present at the facility 24 hours 7 days. LIC stated he will submit an updated LIC 500 to the Department.

Based on staff schedule for 12/24/2024, staff are not present between 7am to 1pm, as resident are attending school and day program.

LIC stated R1 has returned to the facility on 12/24/2024, but was not present during today’s visit since R1 was visiting friends. ADM stated he is updating R1’s Appraisal/Needs and Services Plan. LIC stated he is considering eviction notice for R1.LPA Rai provided California Code Regulation 80068.5 and 85068.5 for Eviction Procedure and to follow the facility’s “Eviction Procedures” on page 63 of Plan of Operations.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 12/26/2024
NARRATIVE
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Page 2 of 3.
On 12/6/2024, the Department received SIR for incident occurred on 12/4/2024. On 12/4/2024 at 9:19pm, R1 signed out of the facility log to visit friends 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 12/10/2024 LPA Rai interviewed (ADM) Avery Manibusan. ADM stated R1 moved into the facility on 12/2/2024 and they conducted an assessment the same day when R1 arrived at the facility. ADM stated he was not aware of R1 having elopement behaviors. ADM stated R1's Individual Program Plan (IPP) dated 12/6/2023 and Admission Agreement was provided before R1 was admitted to the facility on 12/2/2024. ADM stated they did not meet R1's social work and San Andreas Regional Center (SARC) prior to R1's admission on 12/2/2024. ADM stated Interdisciplinary meeting with San Andreas Regional Center (SARC) was scheduled on 12/6/2024 after R1 was admitted but cancelled due to R1's whereabouts were unknown. On 12/5/2024, 24 hours after R1 left the facility, ADM notified R1's social worker and local law enforcement to submit a missing person’s report.

On 12/9/2024, the Department spoke to licensee (LIC). LIC stated they found out of R1’s elopement history when they called the local law enforcement agency to report the missing person on 12/5/2024. LIC stated the local law enforcement agency representative described multiple incidents wherein R1 left his/her previous facility and missing report was filed. LIC stated they are not aware which licensed facility the resident moved from prior to admission. LIC stated they were not aware of any history of elopement during admission and were not made aware of R1’s past behaviors by SARC representative or R1’s social worker. LIC confirmed of received both R1’s Individual Program Plan (IPP) dated 12/6/2023 and R1’s Admission Agreement from SARC prior to R1 admission on 12/2/2024.

On 12/10/2024, the Department interviewed San Andreas Regional Center representative (RC) regarding the communication between regional center and facility Licensee and Administrator. RC stated facility Licensee and Administrator was informed of R1’s history of elopement and this behavior was documented on both R1’s Admission Agreement and R1’s IPP which was provided prior to R1’s admission to the facility on 12/2/2024. RC stated there were two dates of communication between the regional office and facility Licensee and Administrator on 11/26/2024 and 12/2/2024 wherein RC discussed R1’s history of elopement and other behaviors.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
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: 12/26/2024
NARRATIVE
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Based on review of R1's Individual Program Plan (IPP) dated 12/6/2023 which was provided to facility prior to admission, R1 had a history of elopement and/or AWOL. Based on review of R1's Individual Program Plan (IPP) on page 9, R1 has a "history of eloping...and lack of safety awareness." Based on review of R1's Admission Agreement which was provided to the facility prior to admission, the document states R1's behavior of concern can present as verbal aggression, physical aggression, property destruction, and elopement. The behavior may occur 1-2 times a week with the exception of elopement which may occur daily if R1 is not happy with the placement he/she is residing in. LPA Rai reviewed Admission Agreement was signed by the Licensee but not signed by R1 and/or R1’s responsible party.

Based on review of R1's facility file, R1 does not have documents required which include functional capability, personal rights, medical assessments in the file. ADM stated they were not able to obtain necessary documents prior to R1 moving into the facility as they were rushed to move in resident and did not complete pre-placement assessment until the day of admission on 12/2/2024. Based on review of R1's Appraisal/Needs and Services Plan (LIC 625) dated 12/2/2024, Licensee and Administrator did not identify R1's behavior of elopement and how the facility and staff will meet R1's care needs and supervision. ADM confirmed and admitted that they did not develop a plan of care to address R1’s behavior prior to his/her placement.

Based on review of facility Program Plan on page 65 - 68, Licensee and Administrator did not follow the Admission Procedures such as functional capability, personal rights, and medical assessments were not completed prior to admission and needs and services plan was not completed to address resident's existing behaviors.

Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Licensee (LIC) John Manibusan and Administrator (ADM) Avery Manibusan and a copy of the report was provided. Appeal Rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 12/31/2024 08:48 AM - It Cannot Be Edited


Created By: Simranjit Rai On 12/26/2024 at 10:57 AM
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: SERENITY RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202909

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/27/2024
Section Cited
CCR
85068.1(e)

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85068.1 Admission Procedures
(e) If admission is agreed to, the facility shall obtain the signature of the client, or his/her authorized representative, if any, on the Admission Agreement.
This requirement was not met as evidenced by:
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Licensee and Administrator stated to submit a written plan of action understanding regulation and will ensure Admission Agreement is signed by resident and or resident's authorized representative by POC due date.Licensee and Administrator agreed and understood.
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Based on record review, Licensee signed the Admission Agreement but did not obtain the signature of R1 and/or R1’s authorized representative and Regional Center representative which pose/posed an immediate health, safety, and personal rights risk to persons in care.
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Type A
12/27/2024
Section Cited
CCR80069(b)

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80069 Client Medical Assessment
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.
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Licensee and Administrator stated to submit a written plan of action understanding regulation and will ensure resident's medical assessment is on file by POC due date. Licensee and Administrator agreed and understood.
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Based on record review, R1’s medical assessment was not obtained or kept on file prior to accepting a resident into care on 12/2/2024 which pose/posed an immediate health, safety, and personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 12/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2024


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 12/31/2024 08:48 AM - It Cannot Be Edited


Created By: Simranjit Rai On 12/26/2024 at 10:58 AM
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: SERENITY RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202909

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/27/2024
Section Cited
CCR
80069.2(a)

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80069.2 Functional Capabilities Assessment (a) ...the licensee of an ARF shall assess the client's need for personal assistance and care by determining his/her functional capabilities. ...
This requirement is not met as evidenced by:
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Licensee and Administrator stated to submit a written plan of action understanding regulation and will ensure resident's functional capability assessment is completed by POC due date. Licensee and Administrator agreed and understood.
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Based on record review, licensee did not assess R1’s need for personal assistance and care by determining his/her functional capabilities which pose/posed an immediate health, safety, and personal rights risk to persons in care.
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Type A
12/27/2024
Section Cited
CCR85068.2(b)(1)(G)

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85068.2 (b)(1)(G) The licensee shall document the results of the initial assessment of the client, conducted pursuant to Health and Safety Code section 1180.4(a) prior to or on the day of admission... This requirement is not met as evidenced by:
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Licensee and Administrator stated to submit a written plan of action understanding regulation and will ensure resident's Appraisal/Needs and Servies Plan is completed by POC due date. Licensee and Administrator agreed and understood.
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Based on record review, R1 had a history of elopement and prior to admission, Licensee had an incomplete written Appraisal/Need and Service Plan which did not address R1’s history of elopement and facility staff’s plan to meet R1’s needs for care and supervision in relation to elopement or...
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(con't) elopement behavior which pose/posed an immediate health, safety, and personal rights risk to persons in care.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 12/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2024


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 12/31/2024 08:48 AM - It Cannot Be Edited


Created By: Simranjit Rai On 12/26/2024 at 11:04 AM
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: SERENITY RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202909

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/27/2024
Section Cited
CCR
80072(d)

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80072 Personal Rights (d) At admission, a client and the client's authorized representative shall be personally advised of and given a list of the rights specified in Sections 80072(a)(1) through (10) and in the applicable Personal Rights sections of chapters 2 through 7.
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Licensee and Administrator stated to submit a written plan of action understanding regulation and will ensure resident's file contains signed Personal Rights by POC due date. Licensee and Administrator agreed and understood.
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This requirement is not met as evidenced by: Based on record review, R1’s file did not contain signed LIC 613 Personal Rights which shall be given during admission and signature to reflect the list of rights were given to resident and/or resident’s authorized representative which pose/posed an
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(con't) immediate health, safety, and personal rights risk to persons in care.
Type A
12/27/2024
Section Cited
CCR80064(a)(2)

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80064 Administrator - Qualifications and Duties (a) The administrator shall have the following qualifications: (2) Knowledge of the requirements for providing the type of care and supervision needed by clients, including ability to communicate with such clients.
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Licensee and Administrator stated to submit a written plan of action understanding regulation and will ensure Administrator is knowledgable of requirements for providing the type of care and supervision needed by the residents in care by POC due date.
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Based on record review and interview, Administrator did not demonstrate having the knowledge of the requirements to provide residents the appropriate care and supervision which pose/posed an immediate health, safety, and personal rights risk to persons in care.
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Licensee and Administrator agreed and understood.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 12/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2024


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 12/31/2024 08:48 AM - It Cannot Be Edited


Created By: Simranjit Rai On 12/26/2024 at 11:18 AM
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: SERENITY RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202909

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/27/2024
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs.
This requirement was not met as evidenced by:
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Licensee and Administrator stated to submit a written plan of action understanding regulation and will ensure resident's care and supervision needs are met by POC due date. Licensee and Administrator agreed and understood.
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Based on interviews, Licensee and Administrator stated resident was able to enter the facility twice to take personal belongings and take facility vehicle keys while staff were not present at the facility, which pose/posed an immediately health, safety and personal rights risk to persons in care.
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Type A
12/27/2024
Section Cited
CCR80063(a)

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80063 Accountability (a) The licensee, whether an individual or other entity, is accountable for the general supervision of the licensed facility, and for the establishment of policies concerning its operation.
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Licensee stated to submit a written plan of action understanding regulation and will ensure Licensee understands the facility's polices concerning its operation by POC due date. Licensee agreed and understood.
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Based on interview and record review, Licensee did not follow facility's policy and procedures and Title 22 regulations to ensure R1's needs and supervision were met which pose/posed an immediate health, safety and personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 12/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2024


LIC809 (FAS) - (06/04)
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