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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
097005648
Report Date:
09/29/2021
Date Signed:
09/29/2021 11:06:03 AM
Document Has Been Signed on
09/29/2021 11:06 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
,
520 COHASSET RD., STE. 170
CHICO
,
CA
95926
FACILITY NAME:
SERRANO MANOR
FACILITY NUMBER:
097005648
ADMINISTRATOR:
DARYA SELIFANOV
FACILITY TYPE:
740
ADDRESS:
3618 ARCHETTO DRIVE
TELEPHONE:
(916) 293-8385
CITY:
EL DORADO HILLS
STATE:
CA
ZIP CODE:
95762
CAPACITY:
6
CENSUS:
6
DATE:
09/29/2021
TYPE OF VISIT:
POC
UNANNOUNCED
TIME BEGAN:
10:45 AM
MET WITH:
Olga Gudmac
TIME COMPLETED:
11:15 AM
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Plan of correction visit to clear the deficiency from the 9/20/21 case management - deficiencies visit. The sole deficiency from that visit has been cleared. There are no outstanding deficiencies at this time.
SUPERVISORS NAME
:
Laura Munoz
LICENSING EVALUATOR NAME
:
Michael Smith
LICENSING EVALUATOR SIGNATURE
:
DATE:
09/29/2021
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/29/2021
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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