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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701404
Report Date: 10/28/2024
Date Signed: 10/28/2024 12:13:16 PM

Document Has Been Signed on 10/28/2024 12:13 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SERENITY CARE HOMES LLCFACILITY NUMBER:
342701404
ADMINISTRATOR/
DIRECTOR:		AWA, LATIFAFACILITY TYPE:
740
ADDRESS:2519 NEPTUNE COURTTELEPHONE:
(510) 731-4319
CITY:TRACYSTATE: CAZIP CODE:
95304
CAPACITY: 6CENSUS: 0DATE:
10/28/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Latifa Awa TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 10/28/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived announced to this facility to conduct a pre-licensing visit. LPA was greeted by applicant, Latifa Awa and explained the purpose of the visit. The purpose of this visit was to complete a pre-licensing visit.
Current Census 0.

This facility will hold 6 elderly residents, 1 can be deemed bedridden, and 2 can be deemed non-ambulatory. A brief interview with Latifa Awa. This facility will hold a dementia plan on file and hospice waiver for 3.
LPA Pascua initiated a tour of the facility with Applicant, Latifa Awa.
One fire extinguisher was placed in the kitchen and was purchased with a receipt dated on 07/08/2024.
The facility will have a centralized screening point supplied with hand sanitizer and masks located by the entrance and exits.
All rooms designated as activity areas and common areas for resident use were toured. Furniture and furnishings were observed to be present and sufficient to meet the needs of the residents at this time.
Office rooms and other areas intended for resident use were toured.
Kitchen area was toured. Facility freezer and refrigerator units were toured. LPA reviewed the food storage supply to make sure that there was always a 2-day perishable and 7-day nonperishable food quantities on site at all times. Knives were observed to be locked and made inaccessible.
Storage area for chemicals and cleaning supplies were observed to be locked and made inaccessible to the residents at this time. Additional incontinent supplies were also identified.
A tour of 4 resident bedrooms was conducted. Furniture and furnishings were observed to sufficient and able to meet the needs of the residents at this time.
A review 3 resident restrooms was conducted. Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees
First aid kit was observed to be present and contained all of the required components at this time.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SERENITY CARE HOMES LLC
FACILITY NUMBER: 342701404
VISIT DATE: 10/28/2024
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A tour of the laundry room was conducted. LPA observed toxins and laundry detergent locked and made inaccessible.

This facility will be using a locked medication cabinet located in the family room. LPA observed the medication cabinet to be locked and made inaccessible at this time.

Exterior grounds of this facility was toured. Perimeter fence and gates were observed to be functional and in good repair at this time. LPA Pascua observed a locked gate to the man made lake of the community.

This facility has been observed to be in compliance at this time. Component III was reviewed with applicant, Latifa Awa.

There were no deficiencies observed during the course of this Prelicensing visit.

Exit Interview was conducted and a copy of this report was provided to the Administrator.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC809 (FAS) - (06/04)
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