342701404-11-25-2025-27-AS-APAA-DNRRHK-20251125120228

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701404
Report Date: 11/25/2025
Date Signed: 11/25/2025 12:02:38 PM

Document Has Been Signed on 11/25/2025 12:02 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 LLC		FACILITY NUMBER:	342701404
ADMINISTRATOR/ DIRECTOR:	AWA, LATIFA		FACILITY TYPE:	740
ADDRESS:	2519 NEPTUNE COURT		TELEPHONE:	(510) 731-4319
CITY:	TRACY	STATE: CA	ZIP CODE:	95304
CAPACITY: 6		CENSUS: 4	DATE:	11/25/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Latifa Awa		TIME VISIT/ INSPECTION COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 11/25/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived unnanounced to this facility to conduct an annual visit. LPA Pascua met with Staff Member (SM) Yasmin Wahid., and explained the purpose of the visit. LPA Pascua asked SM Wahid to contact the Facility Designated Administrator (FDA), Latifa Awa to inform her that CCL was present. LPA Pascua was able to speak with Facility Designated Representative (FDR), Adham Awa stating that he and FDA Awa were on their way to the facility. There was a housekeeper present at the facility, Fawzia Azizi . Shortly after, LPA was greeted by FDA and FDR. Current census was 4. This facility is licensed to accept 6 elderly residents of whom 1 may be non-ambulatory, and 1 may be bedridden. This facility also has a dementia plan on file and a hospice waive for 3. LPA Pascua reviewed 4 resident files. All resident files were incomplete. LPA Pascua observed through the Licensing Information System, (LIS), that 3 staff members were not associated to the facility at this time. LPA Pascua reviewed 4 resident files. The facility designated administrator has an active administrator certificate #7022761740 and expires on 09/24/2026. One fire extinguisher was placed in the kitchen and was purchased with a receipt dated. 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.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Arielle Pascua
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/25/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2025

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 4

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)

Page: 2 of 4

Document Has Been Signed on 11/25/2025 12:02 PM - It Cannot Be Edited

Created By: Arielle Pascua On 11/25/2025 at 10:16 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SERENITY CARE HOMES LLC	FACILITY NUMBER: 342701404
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(1)

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in by not ensuring that 3 out 3 staff members were not criminally background cleared by the department. This poses an immediate, health, safety, and personal rights risks to persons in care.
	POC Due Date: 11/25/2025
	Plan of Correction
1 2 3 4	Licensee shall associate all staff to the facility roster. A statement of acknowledgement shall be sent to the LPA by 11/25/2025 end of business 5:00PM.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:

	Arielle Pascua
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/25/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2025

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: 11/25/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

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.
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.
The following forms and documents were requested to be submitted:
-LIC 308
-LIC 400
-LIC 500
-LIC610e.
Technical assistance was issued for Sections 87506 and 87412. An immediate civil penalty of $700 was issued for Sections 87355(e)(1).
Licensees were offered and agreed to an opportunity to participate in Department's Technical support Program.
Per California Code of Regulations (CCR) – Title 22 – Division 6, Chapter 6, deficiencies were observed during today’s visit. Citations can be found on the LIC 809 – D. Failure to correct deficiencies may result in civil penalties. Appeal Rights were provided to facility staff. An exit interview was held, and a copy of the report was provided in-person.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Arielle Pascua
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/25/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2025

LIC809 (FAS) - (06/04)

Page: 4 of 4