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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701203
Report Date: 04/03/2023
Date Signed: 04/03/2023 03:58:32 PM

Document Has Been Signed on 04/03/2023 03:58 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:
04/03/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Mama NgaimaTIME COMPLETED:
04:30 PM
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LPA Kesha Lewis made an unannounced health and safety check. LPA met with Staff. LPA explained the purpose of the visit to conduct a health and safety check of the facility.

Health and Safety check included overall safety of the facility including food supply, physical plant and staffing. The facility has a sufficient 2 day supply of perishable food and 7 day non perishable food.

Civil penalties are being issued from the post licensing visit conducted on March 27th the Plan of correction (POC) was never completed.

Exit interview conducted and a copy of the report left at facility.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 04/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2023
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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