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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209174
Report Date: 11/29/2021
Date Signed: 11/30/2021 10:52:28 AM

Document Has Been Signed on 11/30/2021 10:52 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 ESCALONFACILITY NUMBER:
107209174
ADMINISTRATOR:FLORES, GINAFACILITY TYPE:
740
ADDRESS:363 W ESCALON AVE.TELEPHONE:
(408) 712-3040
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY: 6CENSUS: 0DATE:
11/29/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Licensee, Gina FloresTIME COMPLETED:
01:26 PM
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On 11/29/2021 Licensing Program Analyst (LPA) M. Garza arrived at the facility to complete a Pre-Licensing visit with Licensee, Gina Flores. LPA met with Gina and was permitted entry into the facility. COVID-19 screeening measures in place. A complete tour, inside and out, was conducted with Licensee and LPA..

Facility was observed at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. Common areas were properly furnished and well-lit throughout. The tour started in the bedrooms. Residents bedrooms were observed to be adequately furnished with bed, dressers, night stands and adequate lightning. Bathrooms were properly equipped with non-skid mats and securely fastened grab bars. Hot water was tested in two sinks at degrees 108 and 112 F. An adequate supply of linens and personal hygiene supplies were observed. There are no bodies of water outside. Fire extinguisher was observed with a service date of 10/20/2021. Carbon monoxide and smoke detectors were tested and observed to be operational. Cleaning supplies and chemicals were observed locked in the laundry area, under sinks and in the locked garage. First Aid Kit was checked and observed to have the required supplies. The tour concluded in the kitchen. Medications will be kept in a locked closet in the kitchen. Dining utensils were observed. Emergency exit plan, phone numbers, and required postings were observed. A working telephone was present.

Pre-Licensing is complete and this facility has no deficiencies. Comp III was completed. Exit Interview was conducted with Licensee. A copy of this report will be emailed to: serenitygardenhomes@gmail.com due to COVID precautionary measures being taken. A delivered and read receipt serves as confirmation.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2021
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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