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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201297
Report Date: 12/14/2023
Date Signed: 12/14/2023 12:59:42 PM

Document Has Been Signed on 12/14/2023 12:59 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:SERENE SUITESFACILITY NUMBER:
079201297
ADMINISTRATOR:GUTIERREZ, JONATHANFACILITY TYPE:
740
ADDRESS:1955 TREADWAY LNTELEPHONE:
(925) 286-2221
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY: 6CENSUS: DATE:
12/14/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Jonathan Gutierrez, Licensee TIME COMPLETED:
01:15 PM
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On this day 12/14/2023 at 10:45 AM, Licensing Program Analyst (LPA) Lori Alexander arrived announced to conduct a Prelicensing Inspection. LPA met with Licensee, Jonathan Gutierrez and Administrator, Bradley Sanow and explained the purpose of the visit. The facility currently has no residents.

LPA toured facility with Jonathan and Bradley including but not limited to 6 bedrooms, 2 bathrooms, kitchen, common areas and backyard. Bedrooms and living rooms were equipped with the proper furniture. Bathrooms were equipped with grab bars and non-skid mats. Linens and hygiene supplies were observed inside a cabinet. There is sufficient lighting throughout facility. Room temperature was maintained at 66 degrees F and hot water temperature was maintained at 105 degrees F. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational and hardwired linked to all the alarms. Fire extinguisher was last serviced on 08/17/2023.

Starting at 12:00 PM, Component III was presented and completed to both Licensee and Administrator.

No issues noted during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed, and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2023
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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