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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201663
Report Date: 11/30/2023
Date Signed: 12/10/2023 01:39:02 PM

Document Has Been Signed on 12/10/2023 01:39 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 LIVINGFACILITY NUMBER:
107201663
ADMINISTRATOR:JONES, JOSIANEFACILITY TYPE:
740
ADDRESS:2605 W. BARSTOW AVENUETELEPHONE:
(559) 449-0504
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY: 6CENSUS: 3DATE:
11/30/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Licensee Josiane JonesTIME COMPLETED:
04:30 PM
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On 11/30/23, Licensing Program Analysts (LPAs) L. Salazar and M. Garza arrived to the facility unannounced to conduct the required annual visit. LPAs were greeted by caregiver, stated the purpose of the visit and were allowed entry into the facility. Licensee was notified and arrived shortly after. LPA L. Salazar reviewed staff and resident records. LPA M. Garza documented details of the annual visit on a separate report.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
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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