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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701203
Report Date: 01/26/2024
Date Signed: 01/26/2024 04:07:43 PM

Document Has Been Signed on 01/26/2024 04:07 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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: DATE:
01/26/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Tracyann NellsonTIME COMPLETED:
03:15 PM
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Licensing Program Analysts (LPA) Kesha Lewis arrived at the facility unannounced for the purpose of conducting a case management visit following up LPA Ruth Wallace's visit on 11/13/2023. During LPA Wallace's visit there was a staff member that had not been finger printed. LPA explained purpose of visit to the staff.

LPA Lewis talked with staff present and checked LIS and guardian to verify the staff was finger printed and associated to the facility. There were two (2) staff members present and one (1) staff member not present. All staff were verified to be fingerprinted and associated to the facility.

Per California Code of Regulations, Title 22 no deficiencies were observed or cited during today's case management inspection.

An exit interview was conducted and a copy of this report was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2024
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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