<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701203
Report Date: 09/14/2023
Date Signed: 09/14/2023 12:34:23 PM

Document Has Been Signed on 09/14/2023 12:34 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:JIGHERE, VIVIENFACILITY TYPE:
740
ADDRESS:1848 CHATFIELD CIRCLETELEPHONE:
(209) 256-2858
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 6CENSUS: 5DATE:
09/14/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Tanja lintonTIME COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LPA Kesha Lewis made an unannounced visit for a incident report received. LPA met with Staff. LPA explained the purpose of the visit.

Case management 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.

During the course of the visit LPA Lewis confirmed that they facility does not kept the key to the medical cabinet in a place that residents could access. The key is now kept only with staff at all times.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2023
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 1