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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208950
Report Date: 06/21/2022
Date Signed: 06/21/2022 11:32:41 AM

Document Has Been Signed on 06/21/2022 11:32 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, 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:
06/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:43 AM
MET WITH:Administrator Gina FloresTIME COMPLETED:
11:35 AM
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On 6/21/2022, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection- Infection Control. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by staff Carlos. Administrator Gina Flores was called and informed of the inspection. A tour of the facility was conducted.

Visitor log-in/temperature check, masks, and disinfection station were observed upon entry. Facility has one entrance/exit point. Facility staff observed without facial coverings.

Facility appeared cleaned with no obstruction or fire clearance issues. Fire extinguisher in kitchen was last serviced on 5/4/2022 and was fully charged. Hand sanitizer was readily available to residents and visitors. Bathrooms observed with trash cans with lids and hand washing signs. LPA toured bedrooms with adequate furnishings and lighting. Adequate supply of linens observed in the hallway closet.

LPA checked residents’ medications and observed a 2-week supply which is kept locked in cabinet in the kitchen. Laundry area observed locked. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Cleaning and PPE supplies were checked. Staff records were reviewed for good health. Resident’s files have updated emergency contact information. No deficiencies were observed.

LPA is requesting the following documents be submitted to the Fresno CCL office by 6/28/2022: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC610E), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

An exit interview was conducted with Administrator. Report signed on-site and printed copy provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2022
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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