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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209023
Report Date: 10/30/2023
Date Signed: 10/30/2023 02:19:49 PM


Document Has Been Signed on 10/30/2023 02:19 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, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:SERENITY SENIOR CAREFACILITY NUMBER:
547209023
ADMINISTRATOR:ESQUIVEL, BRIANNAFACILITY TYPE:
740
ADDRESS:164 EAST YATESTELEPHONE:
(559) 719-7510
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY:6CENSUS: 6DATE:
10/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:04 PM
MET WITH:Brianna EsquivelTIME COMPLETED:
02:50 PM
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Today, Licensing Program Analyst L. Xiong arrived at the facility unannounced to conduct the Annual Inspection. LPA met Licensee/Administrator Brianna Esquivel and inform her the purpose of the visit.

LPA observed a central entry point with a supply of hand sanitizer and a sign in policy that includes documented routine symptom screening for resident's, staff and visitors. LPA introduced self and allowed entrance by DSP staff. All COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry.

B. Esquivel brought facility records for review and provided the facility tour for LPA. Facility appeared clean with no obstruction or fire clearance issues. All common areas have adequate seating and lighting. Resident bedrooms toured, rooms observed to have all required accommodations. Kitchen toured, LPA observed a 2-day supply of perishable and a 7-day supply of non-perishable food available for residents.

Smoke detector and carbon monoxide detectors observed operational during inspection. Fire extinguisher present with a service date of July/2023. Water temperature observed to measure at 107 degrees F.

No deficiencies were observed.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Les XiongTELEPHONE: (559) 410-1772
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023
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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