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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701082
Report Date: 08/04/2022
Date Signed: 08/05/2022 08:53:23 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/05/2022 08:53 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
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:
08/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Maria Angelica SouxouayTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Arielle Pascua arrived at this facility on 08/04/2022 to conduct an unannounced annual visit. LPA Pascua met with Facility Designated Maria Angelica Souxouay and stated the purpose for today's visit. This facility holds a hospice waiver for 6 and has a dementia program on file.

Census was currently 6.

A tour of this facility was conducted.
Administrator holds a current certificate and expires on, 04/29/2023.
The facility has a main entrance COVID screening point.
Fire extinguisher located by the garage door appeared to have been annually inspected on 04/16/2022.
The kitchen area was toured. LPA Pascua observed a sufficient seven days of non-perishable as well as two days worth of perishable food supplies in the main kitchen. Additional perishable supplies were identified in an additional refrigerator located in the garage. Knives and additional cleaning supplies were locked and made inaccessible to the residents at this time.
LPA Pascua observed a locked centralized stored medication cabinet located in the dining room. Along with Administrator, the LPA observed, reviewed, and compared resident medication with the medication dispensing logs. First Aid Kit was present and contained all of the required components.
Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.
A tour of the garage was conducted. Additional storage for supplies were stored in cabinets. A washer and dryer were also identified in the garage. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees. Grab bars were present and in good repair.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2022
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 502701082
VISIT DATE: 08/04/2022
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A tour of the resident bedrooms was conducted. Resident furniture was observed to be sufficient to meet the resident needs at this time. A tour of the staff bedroom was also conducted.

A linen closet was located in the hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time. Additional incontinence supplies were also identified.

The exterior of the physical plant was in good repair with no hazards present. Perimeter fence was observed to be stable and gates were in good repair.

The following forms and documents were requested to be updated and submitted into CCL.

-LIC308

-LIC 400

-LIC 500

-LIC 610

No deficiencies were observed or cited during this annual visit. A copy of this report was given to Facility Designated Administrator.

Exit interview.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
LIC809 (FAS) - (06/04)
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