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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208950
Report Date: 05/18/2021
Date Signed: 05/18/2021 12:18:31 PM

Document Has Been Signed on 05/18/2021 12:18 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 GARDEN HOME 2FACILITY NUMBER:
107208950
ADMINISTRATOR:FLORES, GINA ONAGFACILITY TYPE:
740
ADDRESS:5409 E BUTLER AVETELEPHONE:
(559) 478-4504
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY: 6CENSUS: 5DATE:
05/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Merovic, Staff TIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) S. Moua conducted an Annual Inspection on this date. LPA was met by staff Merovic and stated the purpose of the visit. Administrator Gina Flores was called and informed of the inspection. A tour of the facility was conducted. COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point.

Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Bathrooms have trash cans with lid. Hand washing posters were observed by the bathroom sink. Bedrooms were checked and beds are six feet apart.

LPAs checked residents’ medications and observed a 30-day supply. Food supply was checked and there appeared to be an adequate supply. Cleaning and PPE supplies were checked. Staff records were reviewed for good health and infection control training. Facility staff was observed with mask on. Residents wear masks when away from the community. Resident’s files have updated emergency contact information. Administrator certification is current.

No deficiencies were observed. Exit interview was conducted. Administrator was informed that as a COVID-19 precautionary measure, this report will be emailed with a read receipt. Staff signed the report.
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: See Moua
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2021
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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