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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209023
Report Date: 10/12/2022
Date Signed: 10/12/2022 09:55:17 PM

Document Has Been Signed on 10/12/2022 09:55 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:SERENITY SENIOR CAREFACILITY NUMBER:
547209023
ADMINISTRATOR:ESQUIVEL, BRIANNAFACILITY TYPE:
740
ADDRESS:164 EAST YATESTELEPHONE:
(559) 719-7510
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 6CENSUS: 6DATE:
10/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:12 PM
MET WITH:Brianna EsquivelTIME COMPLETED:
03:45 PM
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On 10/12/22, Licensing Program Analyst (LPA) conducted an unannounced Annual Required Inspection. LPA met with Licensee/Administrator Brianna Esquivel and stated the purpose of the visit. All COVID-19 guidelines continue to be in place. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point, all staff and visitors observed to be wearing masks.

Facility toured. All residents present during today's inspection. Facility observed to be clean and odor free. All common areas have adequate seating. Kitchen toured, LPA observed 2-day supply of perishable food and 7-day supply of non-perishable food available. Resident bedrooms toured, facility has 4 private bedrooms and 1 shared bedroom. All resident bedrooms have private bathrooms. All bathrooms have grab bars and non-skid mats, trash cans with lids, and hand washing signs in each bathroom. Medication observed to be locked and secured in kitchen cabinet.

Fire extinguisher present and has a service date of 8/30/22. Carbon monoxide detector present and observed to be operational during today's inspection. Personal Protective Equipment (PPE) is stored on site and available if needed. All chemicals observed to be locked and secured.

No deficiencies were observed.

Exit interview was conducted. Facility report signed and a copy provided to Licensee for facility records.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2022
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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