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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202635
Report Date: 03/09/2026
Date Signed: 03/09/2026 04:23:16 PM

Document Has Been Signed on 03/09/2026 04:23 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:LIVE IN SERENITYFACILITY NUMBER:
445202635
ADMINISTRATOR/
DIRECTOR:		ARCILLA, JOSEPHINEFACILITY TYPE:
740
ADDRESS:1340 17TH AVETELEPHONE:
(831) 818-8372
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY: 32CENSUS: 9DATE:
03/09/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Staff Jason Arcilla
Staff Sarah Galura
Staff Minerva Velasco		TIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection and met with Staff Jason Arcilla, Staff Sarah Galura, and Staff Minerva Velasco. LPA stated the purpose of the visit.

LPA toured the interior and exterior of the facility with Staff to include the kitchen, resident rooms, dining room, bathrooms, back and front of the facility. All exit and passageways were free and clear of obstruction. LPA observed the facility to be clean, safe, sanitary and in good repair.

LPA toured Building 1 and Building 2 of the facility. Each kitchen area was observed with a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed each refrigerator temperature at 37 F and Freezer at 0 F in both kitchens.

LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care in both Buildings 1 and 2.

The facility was equipped with smoke and carbon monoxide detectors. The smoke detector/fire system was inspected by a third party vendor on 2/26/2026, and passed inspection. Fire extinguishers were last serviced on 9/16/2025 in Buildings 1 and 2. The facility emergency drill log was reviewed. The facility's last drill was on 1/16/2026.

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NAME OF LICENSING PROGRAM MANAGER: Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2026
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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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: LIVE IN SERENITY
FACILITY NUMBER: 445202635
VISIT DATE: 03/09/2026
NARRATIVE
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LPA toured 6 resident bedrooms (3 in Building 1, and 3 in Building 2). All 6 resident rooms have a bed, functioning lights, dresser/table, bedding and space for personal belongings. LPA toured 2 bathrooms. All 2 bathrooms had hand soap, paper towels, functioning lights, and covered trash bins. LPA measured water temperature with a range of 109.4 F to 117.3 F.

LPA reviewed 3 resident records. Resident records included emergency contact information, physician’s report, needs and service plans, and personal rights.

LPA reviewed 2 resident’s Centrally Stored Medication and Destruction Records (CSMDR’s).

LPA reviewed 3 staff records. 2 Out of 3 Staff records included fingerprint background clearance, medical assessment with TB result, personnel record. Staff Minerva stated training records were in an online system and would provide copies of 3 staff training records to CCL by 3/10/2026. LPA also observed that S1's file did not contain a fingerprint background clearance. Staff Minerva stated S1 did not complete his/her fingerprints.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500) for S1 working in the facility without receiving a criminal record background clearance.



An exit interview was conducted with Staff Minerva Velasco and a copy of this report and appeal rights were provided.

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END OF REPORT

NAME OF LICENSING PROGRAM MANAGER: Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/09/2026 04:23 PM - It Cannot Be Edited


Created By: Marcella Tarin On 03/09/2026 at 04:08 PM
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: LIVE IN SERENITY
FACILITY NUMBER: 445202635

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review the licensee did not comply with the section cited above. S1 did not obtain a criminal background clearance before working at the faclity which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/10/2026
Plan of Correction
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Licensee states S1 is going to get his/her finger prints completed. Licensee stated she will send a plan of action on how she will ensure all staff are finger print cleared before working at the facility.
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.
Christine Kabariti
NAME OF LICENSING PROGRAM MANAGER:
Marcella Tarin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2026


LIC809 (FAS) - (06/04)
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