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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004034
Report Date: 03/23/2022
Date Signed: 04/04/2022 10:08:47 AM


Document Has Been Signed on 04/04/2022 10:08 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:SERENE VALLEY CARE HOMEFACILITY NUMBER:
306004034
ADMINISTRATOR:OSCAR SAMSON/REBECCA ROBISFACILITY TYPE:
740
ADDRESS:24321 BLUERIDGE ROADTELEPHONE:
(949) 951-1948
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 3DATE:
03/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Staff Diosdado and Fritney PerezTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Michelle Reed made an unannounced visit to the facility to conduct an Annual visit. Upon arrival LPA met with Staff Fritney and Diosdado Perez. Administrator Oscar Samson was spoken to via telephone. He could not come to facility. The focus of the visit was Infection Control. The facility was toured with Ms. Perez and the following was observed:

Covid signs were posted in the facility and a sanitization station was set up near the front entrance. LPA's temperature was taken upon arrival and a sign in sheet was available. Facility has required Department postings. Restrooms observed contained soap and toilet paper. Paper towels are also available. Hand sanitizer, soap, wipes and gloves were present and in sufficient supply. The Licensee has at least a 30 day supply of PPE. LPA observed an outside visitation area with ample shading. There were two residents present. Residents were observed watching a movie. Administrator Certificate for Oscar Samson expires 1/13/2023. Social Distancing and masks were observed. Licensee has required Mitigation plan and Emergency Disaster Plan. Facility has emergency food and water supply. Facility has a secured medication drawer for resident medication and files.

During the visit, LPA consulted with staff regarding the importance of maintaining a 30 day supply of PPE on site. Additionally, LPA advised the importance of masks and hand washing for staff, visitors, as well as residents. Administrator is reminded to review Department PINS in regards to Masking, Staff and Resident Testing, Visitation, Dining, Group Activities, Non-essential services, Outings, New Admissions and Entertainment. No deficiencies noted during visit. An exit interview was conducted and a copy of this report was provided to Fritney Perez.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2022
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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