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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803610
Report Date: 12/29/2022
Date Signed: 12/29/2022 09:00:23 AM


Document Has Been Signed on 12/29/2022 09:00 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:SERENITY VILLAFACILITY NUMBER:
496803610
ADMINISTRATOR:REZNIK, AIDAFACILITY TYPE:
740
ADDRESS:477 PETALUMA AVENUETELEPHONE:
(415) 609-3827
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY:21CENSUS: 16DATE:
12/29/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Erika Campos - AdministratorTIME COMPLETED:
09:00 AM
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Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Case Management follow up visit due to deficiencies that were observed during Annual Inspection. LPA met with Administrator Erika Campos for todays visit.

During Annual Inspection 12/20/2022 LPA observed a one piece combination lock on patio exit gate, that was removed during time of visit. Facility was cited for fire clearance safety, inabeling anyone not having the combination, the ability to exit in the event of an emergency. Facility submitted a plan of correction to not have gate locked until Fire Department Inspection changes the fire clearance which will have to be submitted to Community Care Licensing for approval. During today's inspection LPA observed no locks on patio exit gate.

Cleared POC letter given to Administrator at time of visit.


No deficiencies observed during today's visit.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2022
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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