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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803720
Report Date: 03/21/2024
Date Signed: 03/21/2024 03:09:15 PM


Document Has Been Signed on 03/21/2024 03:09 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:SERENITY VILLA IIFACILITY NUMBER:
496803720
ADMINISTRATOR:REZNIK, AIDAFACILITY TYPE:
740
ADDRESS:184 BOAS DRTELEPHONE:
(415) 609-3827
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:12CENSUS: 11DATE:
03/21/2024
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
02:06 PM
MET WITH:Oralia Vera (staff/caregiver)TIME COMPLETED:
03:24 PM
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Licensing Program Analyst (LPA) Cuadra arrived to conduct collateral visit to interview with residents in care regarding complaints unrelated to this facility and met with Oralia Vera, facility staff.

No deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
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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