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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202635
Report Date: 03/21/2025
Date Signed: 03/21/2025 01:03:38 PM

Document Has Been Signed on 03/21/2025 01:03 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:LIVE IN SERENITYFACILITY NUMBER:
445202635
ADMINISTRATOR/
DIRECTOR:
ARCILLA, JOSEPHINEFACILITY TYPE:
740
ADDRESS:1340 17TH AVETELEPHONE:
(831) 818-8372
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
03/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:40 AM
MET WITH:Staff-Minerva VelascoTIME VISIT/
INSPECTION COMPLETED:
01:05 PM
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Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection visit, and met with Staff Minerva Velasco. Administrator (ADM) Jospehine Arcilla was not at the facility during inspection. During the visit, LPA observed 3 residents and 2 staff.

LPA toured the facility with Staff to include the living room, kitchen, dining room, 3 restrooms and 6 residents bedrooms, front yard and backyard. All exits and passageways were free and clear of obstruction.

While touring the facility, Staff informed LPA that buildings 2 and 3 were still under construction. Staff stated all 3 residents are staying in building 1. LPA advised facility to inform the Department once the construction is complete in building 2 and 3.

LPA toured the kitchen and observed a two day perishable food supply and seven day nonperishable food supply. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 74 degrees F, and hot water temperature was measured with a range of 109.4 to 116.2 F in 2 resident bathrooms.

The facility was equipped with smoke and carbon monoxide detectors and were last inspected on 12/10/2024. Fire extinguishers were last serviced on 9/17/2024. LPA reviewed the facility first aid kit. The facility emergency drill log was reviewed. The facility's last drill was on 2/11/2025.

LPA reviewed facility records for 3 staff and 4 residents. LPA reviewed 3 resident medications and centrally stored medication record.

No deficiencies cited during today's visit. A Technical Assisted was provided seeLIC9102. This report was reviewed with Staff Minerva Velsaco and a copy of the signed report was provided.
Jin JackieTELEPHONE: (714) 319-3786
Marcella TarinTELEPHONE: (714) 328-5152
DATE: 03/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2025
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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