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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701480
Report Date: 10/03/2024
Date Signed: 10/03/2024 07:37:03 PM

Document Has Been Signed on 10/03/2024 07:37 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SERENITY HOME CARE II LLCFACILITY NUMBER:
502701480
ADMINISTRATOR/
DIRECTOR:		SOUXOUAY, MA.ANGELICA ABELFACILITY TYPE:
740
ADDRESS:3009 SOUTHWELL LNTELEPHONE:
(209) 526-2425
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 0DATE:
10/03/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Maria Angelica SouxouayTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 10/03/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived announced to this facility to conduct an annual visit. LPA met with applicant, Maria Angelica Souxouay and explained the purpose of the visit. The purpose of this visit was to conduct a Pre-Licensing Visit.

This facility will hold 6 residents, of which 5 may be non-ambulatory and 1 may be bedridden. This facility also has a dementia plan on file with a hospice waiver for 6 residents.
Current census was 0. A brief interview with applicant Souxouay was conducted.

The perspective facility administrator has an active administrator certificate #6016477740 and expires on 04/29/2025.

A tour of the facility was conducted.
A tour of the kitchen was conducted. LPA observed a sufficient amount of 2-day perishable and 7 day non-perishable food supply. LPA observed knives and toxins locked and made inaccessible to residents in care. A medication cabinet was identified in the cabinet in the kitchen. A fire extinguisher was also located in the kitchen and was purchased on 06/08/2024 with a receipt attached to it.
A tour of the back yard was conducted with no hazards present. Perimeter fence and exit gates were observed to be in good repair.
A tour of the living area, dining area, and other areas intended for resident use was conducted. Furniture was observed to be in good repair and meet resident needs.
A tour of 3 bathrooms were conducted. Hot water was taken to ensure compliance within regulation. Grab bars were present and in good repair.
A tour a 4 resident bedrooms were conducted. Resident furniture was observed to be in good repair and meet residents needs. An additional staff bedroom was toured.
A tour of the laundry room was conducted. Toxins and other cleaning supplies were identified and made inaccessible to residents in care.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SERENITY HOME CARE II LLC
FACILITY NUMBER: 502701480
VISIT DATE: 10/03/2024
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A linen closet was identified and presented a sufficient amount of linens to meet the needs of the residents.
Emergency lighting was present throughout the home. Carbon monoxide and smoke alarms were observed and tested to ensure it was in proper working condition. The facility temperature was at 72.

Based on the observations made during this visit, this applicant has passed the pre-licensing inspection.
Component III was reviewed with this applicant.

An exit interview was conducted and a copy of this report was provided to the applicant at the end of this visit.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC809 (FAS) - (06/04)
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