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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602675
Report Date: 08/29/2023
Date Signed: 08/29/2023 02:47:20 PM

Document Has Been Signed on 08/29/2023 02:47 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:JMO SERENITYFACILITY NUMBER:
198602675
ADMINISTRATOR:SANCHEZ, ELLERANNEFACILITY TYPE:
735
ADDRESS:20505 SHADOW MOUNTAIN RDTELEPHONE:
(909) 957-5620
CITY:WALNUTSTATE: CAZIP CODE:
91789
CAPACITY: 4CENSUS: 4DATE:
08/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:49 AM
MET WITH:Alicia Federspiel, House ManagerTIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection. LPA met with House Manager, Alicia Federspiel, and discussed the purpose of the visit. The facility is licensed for 4 adults, ages 18 to 59, of which 1 may be non-ambulatory. The facility is vendorized by the San Gabriel/Pomona Regional Center.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools to inspect the facility and observed the following:
Infection Control: Staff are performing hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting at least twice a day. Facility has submitted the Infection Control Plan. Operational Requirements: The fire clearance is approved for (4) ambulatory clients and (1) may be non-ambulatory. There are currently 4 clients who are all ambulatory. Physical Plant & Environment Safety: The facility consists of 4 client bedrooms, 2 bathrooms, living room, dining room, kitchen, and an attached garage. Carbon monoxide detector is located in the hallway and is operable. Knives are locked. Cleaning solutions and disinfectants are stored and locked in a garage cabinet. There are no swimming pool or other bodies of water on the premises. The hot water was measured within the required range of 105-120 degrees F. Staffing: Per staff, there are 2 staff in the morning and evening shifts and one awake staff for the overnight shift. The administrator certificate for Elleranne Sanchez expires on 1/8/25. Administrator's HIV and TB Training certificate is dated 10/21/22. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for 4 Staff. The staff files have the the health screening including TB results, current First Aid & CPR certificates, and on-going training. Client Rights-Information: Client rights are reviewed and signed by client annually. Clients are provided with internet usage and are afforded privacy.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: JMO SERENITY
FACILITY NUMBER: 198602675
VISIT DATE: 08/29/2023
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 Client Records-Incident Reports: LPA reviewed all 4 Client files and they have the required documents on file: Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent forms, Individual Program Plan, and forms for safeguarding property and cash resources.
Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. There are no clients on special diets. Kitchen is kept clean and free from rodents and other vermin.
Health Related Services: The medications are centrally stored and inaccessible to clients. LPA reviewed medication for all 4 clients. The facility uses the Medication Administration Record (MAR) log to document medications given and are being administered as prescribed by the Physician.
Incidental Medical Services: There are (0) clients with restricted health condition plan.
Disaster Preparedness: The facility has the Emergency Disaster Plan with emergency contact numbers, relocation sites, shutoff valves, and evacuation procedures.

No deficiencies were issued today. An exit interview held and a copy of this report was given to the house manager.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
LIC809 (FAS) - (06/04)
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