445202635-1-8-2026-26-AS-MTAN-DQ5QW9-20260108113135

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 445202635
Report Date: 01/08/2026
Date Signed: 01/08/2026 11:31:49 AM

Document Has Been Signed on 01/08/2026 11:31 AM - 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:	LIVE IN SERENITY		FACILITY NUMBER:	445202635
ADMINISTRATOR/ DIRECTOR:	ARCILLA, JOSEPHINE		FACILITY TYPE:	740
ADDRESS:	1340 17TH AVE		TELEPHONE:	(831) 818-8372
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95062
CAPACITY: 8		CENSUS: 5	DATE:	01/08/2026
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Licensee Jesus Arcilla Administrator Minerva Velasco		TIME VISIT/ INSPECTION COMPLETED:	11:30 AM

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	Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced Case Management visit to follow up on the facility's capacity increase request. LPA met with Licensee Jesus Arcilla and Administrator (ADM) Minerva Velasco. LPA stated the purpose of the visit. On 07/18/2025 the Department received a capacity increase request from Licensee Josephine Arcilla. Licensee requested an increase in capacity from eight (8) to thirty-two (32) on 7/14/2025. This facility has 2 separate buildings, Building #1 and Building #2, which share the same address. Licensee requested 1 ambulatory, and 31 bedridden, with a total capacity of 32. A Fire Clearance request was submitted to the local fire department on 8/26/2025. On 12/29/2025 the Department received the fire clearance approval: Building 1-Rooms 1-4, and 6 approved for bedridden or non-ambulatory residents, Room 5-approved for ambulatory ONLY. Building 2-Rooms 1-12 approved for bedridden or non-ambulatory. During today's visit, LPA inspected 6 bedrooms in Building 1, which currently has 5 residents, all exit doors/sliding glass doors are equipped with auditory alarms. LPA inspected Building #2, to include all 12 bedrooms. All 12 bedrooms had a bed, dresser, chair, and space for personal belongings and functioning lights. All 12 bedroom exit doors/sliding doors are equipped with auditory alarms. All 12 bedroom auditory alarms functioned properly when tested by the Licensee and ADM. Building 2 does not currently have any residents. Licensee and ADM were advised the facility cannot accept residents until the Department has processed all documentation for the capacity increase. Licensee and ADM stated understanding. No deficiencies cited during today's visit per California Code of Regulations, Title 22. An exit interview was conducted with ADM Minerva Velasco and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/08/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2026

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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