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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576804274
Report Date: 01/23/2026
Date Signed: 01/27/2026 11:39:29 AM

Document Has Been Signed on 01/27/2026 11:39 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 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:
01/23/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Queenie M. Atilano, Administrator/LicenseeTIME VISIT/
INSPECTION COMPLETED:
12:22 PM
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On 01/23/2026 Licensing Program Analyst (LPA) Nakagawa conducted an unannounced Annual Inspection and was greeted by Licensee/Administrator, Queenie Atilano. This facility has approval for six ambulatory clients; two for each unit of the facility. There are currently no clients in care. Facility is undergoing a change in ownership.

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. A fire extinguisher is located in the kitchen of each unit and was found to be fully charged. 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. Water was measured at approximately 113 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, with consideration to client preferences and dietary restrictions.

Continued on 809-C.
NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Jill Nakagawa
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 01/23/2026
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Continued from 809...

Medications will be centrally stored and secured in locked cabinet located in the office unit. Licensee was unable to provide records for personnel training and other staff records. (See Deficiency 809-D),The facility has all appropriate public documentation and personal rights information posted in common spaces within the facility. The facility is equipped with a sufficient amount of activities including internet access. Outings are planned for the farmer's market, hikes, and activities at the nearby university and country club when clients return. Therapists have been contracted and additional activities for clients will be included depending on client needs and interests.

Deficiency cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.





NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Jill Nakagawa
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/27/2026 11:39 AM - It Cannot Be Edited


Created By: Jill Nakagawa On 01/23/2026 at 11:11 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SERENITY NOW-SALEM
FACILITY NUMBER: 576804274

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/23/2026
Section Cited
CCR
81063(a)

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81063 (a)The licensee....is accountable for the general supervision of the licensed facility....concerning its operation.
This requirement is not met as evidenced by:
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POC: Licensee will provide information to CCL regarding the operation of the facility within a reasonable amount of time as requested by the LPA and the particular circumstances beginning 1/23/2026.
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Based on LPA's visit on 10/15/2025 and subsequent request for information on 10/16/25,10/21/2025, 12/16/2025 and 12/29/2025 from the house manager and Adm./Licensee that were unmet, the licensee is accountable for providing the information to LPA's requests.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Jill Nakagawa
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2026


LIC809 (FAS) - (06/04)
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