306004034-3-23-2024-22-AS-CDPO-D3MQZP-20240323123705

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004034
Report Date: 03/23/2024
Date Signed: 03/23/2024 12:37:23 PM

Document Has Been Signed on 03/23/2024 12:37 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	SERENE VALLEY CARE HOME		FACILITY NUMBER:	306004034
ADMINISTRATOR:	OSCAR SAMSON/REBECCA ROBIS		FACILITY TYPE:	740
ADDRESS:	24321 BLUERIDGE ROAD		TELEPHONE:	(949) 951-1948
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	6	CENSUS: 6	DATE:	03/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:13 AM
MET WITH:	Irene Wong-Samson - Licensee		TIME COMPLETED:	12:42 PM

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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced visit for the Required 1 Year Inspection. LPA explained the purpose of today’s visit, and was greeted and granted entry by licensee (LE) Irene Wong-Samson.

For today’s visit, LPA observed a total of 6 residents in care and 2 staff members on duty.

LPA observed the Administrator's Certificate for facility administrator (AD) Oscar Samson which expires on 1/13/2025.

LPA De Perio toured the interior and exterior portions of the facility with S1 Granada. The facility is a single level structure and is licensed for 6 residents. For this visit, there are a total of 6 residents in care. There are a total of 5 bedrooms, of which 2 is a private resident room, 2 are shared resident rooms, and 1 room designated for staff. LPA De Perio toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. It was observed that there are a total of 3 restrooms in the facility. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured to be at 108.2 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguisher was charged, mounted and located in the hallway.

LPA De Perio observed the emergency disaster and evacuation plan, which is posted in the hallway and in a binder. Facility had back-up emergency food and water supply, located in the garage and in the kitchen.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SERENE VALLEY CARE HOME	FACILITY NUMBER: 306004034
	VISIT DATE: 03/23/2024

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LPA De Perio observed that First Aid Kit had all the required components. LPA De Perio observed that medications and toxins were locked and inaccessible to residents in care.

For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There are 2 gates in the backyard, which both were self-closing and self-latching. No bodies of water were observed.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

No citations were issued.

An exit interview was conducted with LE Wong-Samson.

A copy of this report was provided and explained.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2024

LIC809 (FAS) - (06/04)

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