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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701203
Report Date: 11/22/2022
Date Signed: 11/30/2022 03:02:35 PM

Document Has Been Signed on 11/30/2022 03:02 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
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:
11/22/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ikiseh ChukwudiTIME COMPLETED:
03:00 PM
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Licensing Program Analysts (LPA) Kesha Lewis and Albert Johnson contacted the facility to commence an announced Pre-Licensing visit on 11/22/2022 at 1:00pm to ensure compliance with Title 22 regulations.

LPA'S was allowed entry into the facility that will be licensed for a capacity of 5 non-ambulatory residents. LPA'S met with Ikiseh Chukwudi, future administrator who assisted with today’s visit. Administrator certificate number #6064223740 expires 10/06/2024.

LPA toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. LPA observed there are no residents at this time.

LPA observed the kitchen area, dining area, bedrooms, bathrooms, storage areas, garage, and laundry room. LPA observed knives/sharps, medications, and records storage to be locked. LPA observed required furniture, and lighting throughout the facility.

Pre licensing Inspection and Component Three completion and verification email sent to CAB on 11/23/2022.

Exit Interview conducted and a copy of the report was left at facility.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2022
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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