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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507003678
Report Date: 08/20/2021
Date Signed: 08/20/2021 02:39:08 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SERENITY HILL RESIDENTIAL CARE HOMEFACILITY NUMBER:
507003678
ADMINISTRATOR:ABANIA, JACINTA ALENI T.FACILITY TYPE:
740
ADDRESS:643 HILL ROADTELEPHONE:
(209) 848-2238
CITY:OAKDALESTATE: CAZIP CODE:
95361
CAPACITY:6CENSUS: 6DATE:
08/20/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jacinta AbaniaTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Sarah Hurt made an unannounced visit for the purpose of conducting a Case Management Visit. LPA met with Administrator Jacinta Abania and explained the purpose of the visit.

On June 8, 2020 the Department received a request from the facility for a capacity increase. A new fire clearance was requested and approved on 8/10/2021. On this day, LPA toured the facility and observed the facility and discuss the facilities plan for the increased capacity. LPA ensured the rooms had furnishings required such as bed, nightstand, lamp and chair per regulations.

Due to all requirements being met, the facility can now accept up to 12 residents according to their new approved fire clearance.

An exit interview was conducted with Administrator and a copy of this report was provided. A copy of the new license will be mailed to the facility within 2-3 business days.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
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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