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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701203
Report Date: 03/27/2023
Date Signed: 03/27/2023 01:38:13 PM

Document Has Been Signed on 03/27/2023 01:38 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:
(209) 256-2858
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 5CENSUS: 4DATE:
03/27/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Josephie JenkinsTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kesha Lewis arrived to conduct an unannounced Post Licensing inspection on this date. Administrator certificate 6064223740 expires 10/06/2024.

LPA collected Certificate of Insurance for liability and reviewed the Personnel Policies, Abuse Reporting Procedures, In-Service Training and Medication Procedures during the Post-Licensing Inspection.

LPA observed the following posted in the entrance of the facility: Resident Council Rights, See Something Say Something complaint poster, Reporting Requirements per AB40, Resident Bill of rights, Ombudsman Poster, Resident Personal Rights, Evacuation Routes and facility license were all posted as required.

Exit interview held with Administrator and a copy of report was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2023
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 2
Document Has Been Signed on 03/27/2023 01:38 PM - It Cannot Be Edited


Created By: Kesha Lewis On 03/27/2023 at 01:09 PM
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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SERENE RESIDENTIAL CARE HOME
FACILITY NUMBER: 392701203

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
03/28/2023
Section Cited
CCR
87202(a)

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All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
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LPA informed Licensee that the fire exit cannot be block at any time. Licensee will review regulation and submit a letter to LPA Lewis on how the door will be secured in the future via email. LPA had staff remove the stick while still at the facility.
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Based on LPA's observation there is a sick in the back door in the kitchen preventing the door from being opened. After and speaking with the licensee he states "that should have been removed in the morning " This poses an immediate health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Kesha Lewis
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2023


LIC809 (FAS) - (06/04)
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