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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576804274
Report Date: 12/23/2024
Date Signed: 12/23/2024 03:57:13 PM

Document Has Been Signed on 12/23/2024 03:57 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 NOW-SALEMFACILITY NUMBER:
576804274
ADMINISTRATOR/
DIRECTOR:		ATILANO, QUEENIE MFACILITY TYPE:
772
ADDRESS:2927, 2929, 2931 SALEM AVETELEPHONE:
(916) 287-7045
CITY:DAVISSTATE: CAZIP CODE:
95616
CAPACITY: 6CENSUS: 0DATE:
12/23/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Queenie Atilano, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:18 PM
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On 12/23/2024 Licensing Program Analyst (LPA) Nakagawa conducted a pre-licensing inspection and was greeted by Licensee Applicant, Queenie Atilano. This pre-licensing inspection is being conducted for an initial licensing. Fire Clearance has been approved for 6 ambulatory clients; two for each unit of the facility.

LPA conducted a tour and inspection of the indoor and outdoor portions of the facility. Facility was found to be clean and comfortable temperature with bedroom doors free from obstruction. LPA observed a fire extinguisher located in the kitchen of each unit and was found to be recently purchased. Smoke detectors and carbon monoxide detectors located in each common space and client bedrooms were tested and and found to be in working order. Windows and blinds are all found to be in good repair with facility free of insects or pests. Emergency evacuation maps and clear exit signs are posted appropriately. Infection control plan has been updated and protocol infection prevention information are within facility operation binder. Emergency exit along the one side of the facility has appropriate hardware and found to be unobstructed. Water was measured at approximately 117.5 degrees F in faucets used by clients which falls within regulation between 105 & 120 degrees F.

There was an ample supply of extra linens with appropriate bedding. An additional supply of hygiene, continence and paper products are located in hall closet. Client bedrooms were inspected have appropriate furnishing and found to be in a clean and comfortable condition. There is a sufficient amount of dishes and cooking supplies for client use with sharps and other hazardous items kept secured in various designated drawers and cabinets. Cleaning products and other toxins and chemicals are kept out of client access and found secured in hall closet. LPA observed adequate supply of non-perishable food. Perishable foods will be purchased more closely to client admission. The facility will be conducting frequent grocery replenishment with consideration to client preferences and dietary restrictions. A sample menu has been completed and will be updated by chef and dietary consultant regularly.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SERENITY NOW-SALEM
FACILITY NUMBER: 576804274
VISIT DATE: 12/23/2024
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Continued from 809

Medications will be centrally stored and secured in locked cabinet located in the office unit. Licensee applicant has access to all appropriate medication administration documents including the Centrally Stored Medication Records and several other medication related forms and will have available prior to client admission. The facility has all appropriate public documentation and personal rights information posted in common spaces within the facility. The facility has begun the hiring process for direct support staff and have been informed of association process. The backyard features a large lawn and walkways. Seating and a shade structure will be added for client outdoor use when the weather is warmer and drier. The facility is equipped with a sufficient amount of activities including access to the nearby country club. Bikes will be purchased for accessing the area bike paths and additional outdoor recreational items will be purchased, including kayaks and paddle boards. Outings are planned for the farmer's market, hikes, activities at the nearby university. An art therapist has been contracted and additional activities for clients will be included depending on client needs and interests.

Licensee has installed appropriate internet access for each unit and required telephone service within the facility for client use.

Pre-Licensing is complete and this facility has no deficiencies.

Component III orientation was conducted with the Licensee Applicant. The pre-licensing evaluation has been completed. License will be granted upon completion of a final review and approval from the Licensing Program Manager. This report was reviewed and a copy was provided to the Licensee.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC809 (FAS) - (06/04)
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