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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201883
Report Date: 07/09/2025
Date Signed: 07/09/2025 12:21:36 PM

Document Has Been Signed on 07/09/2025 12:21 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
CENTRAL COAST CR/RES, 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:
07/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Melburga SenotTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
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On July 09, 2025, the Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Required 1-Year Annual inspection. The LPA met with the caregiver, Josephine Caliboso, and disclosed the purpose of the inspection. The caregiver informed the LPA that the facility had four (4) residents in care and (2) staff members present at the time. The Licensee, Melburga Senot joined shortly after.

At 9:15 AM, the LPA initiated a walk-through of the facility, accompanied by the caregiver.

LPA inspected the kitchen and there was no food preparation and cooking in progress at the time. The appliances were checked and observed to be in working order. The LPA inspected a locked cabinet containing knives and sharp objects, and a locked cabinet under the sink with detergents and cleaning supplies. The refrigerator and pantry cabinets were inspected, and sufficient supplies of fresh perishable food for (2) days and nonperishable staples for (7) days were observed. No expired food or stored medications were noted.

LPA inspected the dining area adjacent to the kitchen. The dining table and chairs were observed to accommodate the residents, and all the furniture was in good repair. Two (2) residents were observed to eat breakfast on the dining table.

LPA inspected the living room and observed it clean, with all furniture in good repair. There were sofa sets, reclining chairs, tables, and a television in the living room.

There were three (3) bedrooms and (2) bathrooms designated for residents' use. All resident rooms were shared occupancy.

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: SERENITY CARE HOME RCFE
FACILITY NUMBER: 435201883
VISIT DATE: 07/09/2025
NARRATIVE
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LPA inspected all resident rooms and found them clean, well-lit, and equipped with the required furniture. LPA inspected two (2) shared bathrooms and found them sanitary, and in good working condition. The bathrooms contained soap, grab bars, paper towels, a trash can, a shower chair, and non-slip flooring/mats. At 9:42 AM, the hot water temperature at the sink faucet in both the bathrooms was measured between that range of 126.1°F to 126.7°F.

At 09:58 AM, LPA inspected the garage and observed it cluttered with the incontinence supplies, furniture, food supplies, wheelchairs, mattresses, and suitcases. LPA observed a washer and a dryer in the garage.

LPA inspected one (1) storage closet in the hallway and observed that they contained clean linens, blankets, and towels for residents’ use.

LPA inspected the fire extinguisher mounted on the wall in the living room and found it fully charged, with the last service tag dated 01/31/2025. The caregiver tested the smoke and carbon monoxide detector located in living room in the LPA's presence, and it was found to be functional. Additional smoke and carbon monoxide detectors were observed in all bedrooms and common areas of the facility during the visit.

LPA toured the backyard and found ramps and passageways clear of obstructions, with no blocking or tripping hazards. No bodies of water were noted.

LPA reviewed two (2) staff personnel records and four (4) resident records. LPA observed that four (4) of four (4) residents had an Admission Agreement, Physician's Report, Appraisal/Needs and Services Plan, and CSDMR. LPA observed that two (2) of two (2) staff members had current First Aid certificates, LIC 508 Criminal Record Statements, and LIC 503 Health Screenings, and confirmed that two (2) of two (2) staff members were associated with the facility.

LPA observed a locked centrally stored medication cabinet in the kitchen. Medications were organized separately for each resident. All medication bottles and bubble packs were properly labeled. Centrally Stored Medication Records were reviewed. At 10:50 AM, LPA observed that 1 of 4 residents’ R1’s one prescription medication name, prescription number, and date filled were not entered in the Centrally Stored Medication Records (CSMR).

LPA inspected the first aid kit and found it fully stocked.

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: SERENITY CARE HOME RCFE
FACILITY NUMBER: 435201883
VISIT DATE: 07/09/2025
NARRATIVE
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Emergency Drill Logs were reviewed, and it was observed that Emergency Disaster (Fire and Earthquake) Drills were conducted quarterly, with the most recent drill completed on 07/01/2025.

The following updated forms are requested to be submitted to CCLD by 07/16/2025:

  • LIC 500: Personnel Report
  • LIC 308: Designation of Facility Responsibility
  • Certificate of Liability Insurance
  • Administrator Certificate(s)
  • Control of Property (Grant Deed)

The deficiencies are being cited based on LPA observations, records reviewed, and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted, and Plans of Correction were reviewed and developed with the Licensee. A copy of this report and appeal rights were discussed and left with the Licensee, Melburga Senot, whose signature on this form confirms receipt of these documents.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/09/2025 12:21 PM - It Cannot Be Edited


Created By: Kiran Jain On 07/09/2025 at 11:53 AM
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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SERENITY CARE HOME RCFE
FACILITY NUMBER: 435201883

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the Licensee did not ensure garage was clean, organized, and not cluttered, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/16/2025
Plan of Correction
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The Licensee stated that they would clean and organize the garage. The Administrator will submit the Licensee evidence to CCLD by 07/19/2025.
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Licensee did not ensure the hot water in is the range of 105°F-120°F. The hot water temperature at the sink faucet in two bathrooms was measured between that range of 126.1°F to 126.7°F, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/16/2025
Plan of Correction
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The Licensee will submit the POC to CCLD by 07/16/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Kiran Jain
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/09/2025 12:21 PM - It Cannot Be Edited


Created By: Kiran Jain On 07/09/2025 at 11:59 AM
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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SERENITY CARE HOME RCFE
FACILITY NUMBER: 435201883

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(6)(E)
87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (E) The prescription number and the name of the issuing pharmacy.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the Licensee did not ensure that for 1 of 4 resident's medication ‘Paroxetine HCL 20 MG’ prescription names, prescription numbers, issuing pharmacy, and date filled were entered correctly in the Centrally Stored Medication Records, which poses/posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2025
Plan of Correction
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The Licensee will write correct prescription name, numbers, issuing pharmacy, and date filled for R1's medications in Centrally Stored Medication Records and submit the proof of correction to CCL by 07/10/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Kiran Jain
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2025


LIC809 (FAS) - (06/04)
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