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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701203
Report Date: 10/25/2022
Date Signed: 10/25/2022 02:31:53 PM

Document Has Been Signed on 10/25/2022 02:31 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
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:SERENE RESIDENTIAL CARE HOMEFACILITY NUMBER:
392701203
ADMINISTRATOR:IKISEH, CHUKWUDIFACILITY TYPE:
740
ADDRESS:1848 CHATFIELD CIRCLETELEPHONE:
(510) 860-5725
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 5CENSUS: 0DATE:
10/25/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:07 PM
MET WITH:Chukwudi Ikiseh, AdministratorTIME COMPLETED:
02:21 PM
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Component II completion: Successful

Facility Type: Residential Care Facility for Elderly (RCFE)
Application Type: Initial
Capacity: 5
Census (if any clients in care): 0
COMP II Participants: Chukwudi Ikiseh, Administrator
Interview Method: Telephone interview

On October 25, 2022 at 1:00 PM, Administrator participated in COMP II. Identification of the Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Administrator confirmed the understanding of the California Code Title 22 Regulations.

During COMP II, CAB Analyst confirmed Administrator’s understanding of following areas:
1. Facility Operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing Requirements/CPMB Associations & Training
4. Restrictive/Prohibited Health Conditions
5. General Provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing Readiness

Exit interview conducted with Administrator. Report sent via email PDF and informed to return signed copy to CAB by end of business day today.
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2022
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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