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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208950
Report Date: 05/14/2025
Date Signed: 05/20/2025 10:00:16 PM

Document Has Been Signed on 05/20/2025 10:00 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:SERENITY GARDEN HOME 2FACILITY NUMBER:
107208950
ADMINISTRATOR/
DIRECTOR:		FLORES, GINA ONAGFACILITY TYPE:
740
ADDRESS:5409 E BUTLER AVETELEPHONE:
(559) 478-4504
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY: 6CENSUS: 5DATE:
05/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Phoeun Marez, Administrator TIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Rachel Bruce arrived unannounced to conduct the Annual inspection. LPA was granted entry by Caregivers Isagani Colocado and Mae Geradine Guillermo. Administrator, Gina Flores was called and arrived shortly thereafter. Facility was toured with Caregiver, Isagani Colocado.

During this visit, LPA toured the facility and grounds. During this visit, there were 5 residents present. There are 6 resident rooms, all contained required furnishings and lighting and a TV , the hallway had working night lights.

There are 3 bathrooms in this facility. LPA observed grab bars in shower and around toilet, non skid mat in showers, shower chairs, and trash cans with lids. Hot water measured within regulatory requirements. Resident hygiene supplies were properly stored and available.

The kitchen was toured observed in good repair with necessary items and appliances and sharps/knives are stored in locked drawer. Cleaning products and dish soap are stored in locked cabinet below sink. Refrigerator was observed to be at 41 degrees F and Freezer at 0 degrees F. LPA observed 2 day perishable and 7 day non perishable food supply available. No expired food observed. There is a second refrigerator located in garage to hold extra food. Medications are centrally stored and locked in kitchen cabinets. Narcotics requiring refrigeration are stored in a locked box in the garage refrigerator.

There are 2 fire extinguishers in the facility, one in the laundry room and the second in the kitchen. Both were taken for service during the visit. Smoke and Carbon Monoxide detectors are located in each bedroom and in the common areas. Smoke/carbon detectors was tested and found to be functioning; they are interconnected.
NAME OF LICENSING PROGRAM MANAGER: Sergiy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Rachel A Bruce
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: SERENITY GARDEN HOME 2
FACILITY NUMBER: 107208950
VISIT DATE: 05/14/2025
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Facility has designated visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility.

Garage is kept locked. LPA observed locked box of medication in refrigerator for narcotics. Currently there are three residents on hospice. Shelves store extra incontinence and general supplies.

First aid kit found to contain required items.

Laundry room is kept locked. LPA observed the room and appliances to be in good condition. Cleaning products are stored in locked cabinet.

The backyard is well maintained, trees, bushes and grass in good condition. There is a screened pergola with seating for 5. Patio furniture is clean and ready for use. The exterior walkways are free from obstructions and debris.

LPA conducted resident and staff file reviews and all contained required information.

An exit interview was conducted with Gina Flores, whose signature on this form confirms receipt of these documents.
NAME OF LICENSING PROGRAM MANAGER: Sergiy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Rachel A Bruce
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025
LIC809 (FAS) - (06/04)
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