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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201883
Report Date: 07/23/2024
Date Signed: 07/23/2024 04:55:07 PM

Document Has Been Signed on 07/23/2024 04:55 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:SERENITY CARE HOME RCFEFACILITY NUMBER:
435201883
ADMINISTRATOR/
DIRECTOR:
MELBURGA SENOTFACILITY TYPE:
740
ADDRESS:684 LAKEWOOD DRTELEPHONE:
(408) 747-3439
CITY:SUNNYVALESTATE: CAZIP CODE:
94089
CAPACITY: 6CENSUS: 4DATE:
07/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Melburga SenotTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
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Licensing Program Analysts (LPAs) Steve Chang and Marcela Yanez conducted an unannounced annual inspection visit, and met with Administrator (ADM) Melburga Senot.

LPAs observed 3 residents and 1 staff in the facility. LPA reviewed 2 residents files and 2 staff files.

LPAs toured the facility inside and out and ADM. License, expired Administrator Certificate, and personal rights posters were observed in the facility. ADM showed the evidence that he/she renewed the Administrator certificate already.

LPAs toured the facility inside out with ADM. Living room, kitchen, dinning room and two restrooms, 3 resident bedrooms, 1 staff live-in room, and laundry area were inspected. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet and cleaning product room was observed locked. Room temperature was at 78 degree F, and hot water temperature was at 105 degree F in facility.

First aid box, night lights, and flash lights were observed at the facility. The last time the facility conducted the emergency drill is 7/1/2024.

Fire extinguisher was serviced on 2/9/2024. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by staff, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

No deficiency was noted today. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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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