<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701082
Report Date: 08/20/2021
Date Signed: 08/20/2021 04:39:09 PM

Document Has Been Signed on 08/20/2021 04:39 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SERENITY HOME CAREFACILITY NUMBER:
502701082
ADMINISTRATOR:SOUXOUAY, MARIA ANGELICAFACILITY TYPE:
740
ADDRESS:1813 ELDER LN.TELEPHONE:
(209) 345-6618
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 6DATE:
08/20/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:SOUXOUAY, MARIA ANGELICA, ADTIME 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
LPA Garcia conducted this announced prelicensing visit. LPA toured with MARIA ANGELICA SOUXOUAY, Administrator. This facility has a fire clearance for six non-ambulatory and six total. Hospice waiver for 6.
This facility has two private and two shared resident rooms to the left of the main entrance. There is separate staff living quarters for onsite Administrator. There are 3 ramps available for emergency exits for residents. From the main entrance is an open entry welcome area into the dining room and kitchen. Off the open area is an additional seating area for residents with an attached bathroom. From the kitchen is an additional half bath then entry into the garage with the laundry, dryer, and extra storage. There is a common bathroom accessible to three rooms. There is a private bathroom attached to one of the single occupancy room. Carbon monoxide in hallway and central area. Fire alarms in all resident rooms and central area.
Staff and client files are locked in closet area in front centralized office. All cabinets/ closets have keyed locks. The backyard was inspected and there is one gate on south side of the facility. The kitchen was inspected. There is a locked cabinet in kitchen for sharps. There is a locked cabinet that stores the medications. Refrigerated medications will be stored in clear lock box in garage fridge. Controlled medications in lock box in lock cabinet Both front and backyards are well maintained. There are audio alerts on all exits. Each resident has a call system that alerts the caregivers.

Component III orientation completed and certificate posted. The Administrator has 5 years of licensing experience in both ARF and RCFE. Administrator Certificate exp. 6/30/21 with Conditional extension. LPA is going to submit this report to the applications specialist for review.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arlene D Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1