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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920134
Report Date: 01/08/2025
Date Signed: 01/08/2025 01:32:00 PM

Document Has Been Signed on 01/08/2025 01:32 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SERENE RESIDENTIAL LIVINGFACILITY NUMBER:
345920134
ADMINISTRATOR/
DIRECTOR:		SEGUBAN, LIZAFACILITY TYPE:
740
ADDRESS:7125 BRAYTON AVETELEPHONE:
(530) 409-9297
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY: 6CENSUS: 3DATE:
01/08/2025
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:50 AM
MET WITH:Administrator-Liza SegubanTIME VISIT/
INSPECTION COMPLETED:
01:35 PM
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On 01/08/2025 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a post licensing inspection. LPA met with Administrator Liza Seguban and explained the purpose of the visit. Today's census is three (3) residents with two (2) resident on hospice services. Facility is licensed for six (6) residents and hospice waiver of two (2).

LPA and Administrator conducted a tour of the interior and exterior of the facility to ensure the health and safety of residents in care. Areas toured include but not limited to resident bedrooms, bathrooms, kitchen, dinning room, garage and common areas. LPA observed sharps, toxins and medication to be locked and secured. LPA observed the facility to have two (2) days of perishable and seven (7) days of nonperishable foods. LPA observed fire extinguisher to be last serviced on 08/20/24. LPA and Administrator completed the post-licensing inspection tool and facility was found to be in compliance.

LPA conducted a file review of three (3) residents files and (2) personnel files.

As a result of today's inspection, no deficiencies cited.

Exit interview conducted and a copy of the report was left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025
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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