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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004315
Report Date: 03/03/2021
Date Signed: 03/03/2021 05:51:21 PM

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:SERENITY LIVINGFACILITY NUMBER:
306004315
ADMINISTRATOR:PAUL DEJESUSFACILITY TYPE:
740
ADDRESS:29825 ANDREA WAYTELEPHONE:
(949) 481-2444
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:6CENSUS: 3DATE:
03/03/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:49 PM
MET WITH:Administrator Dianna Manalo TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to this facility to conduct a case management. LPA was granted entry by staff after completion of Coronavirus 2019 (COVID-19) check. Thereafter, staff called and informed Administrator Dianna Manalo on the presence of the LPA in the facility. AD arrived shortly after. LPA stated the purpose of the visit.

LPA Marin toured the interior of the facility and observed three resident's in care and 2 staff members on duty. LPA interviewed the staff members and AD Manalo. LPA reviewed the COVID-19 infection control and procedures, and personal protective equipment supply of the facility LPA discussed the Provider Information Notice (PIN) 21-10-ASC N95 Respirator Fit Testing Resources for Adult and Senior Care Residential Facilities.
No citation was issued at this time.

LPA Marin conducted and exit interview with AD Manalo. LPA will provide a copy of this report via email; and AD agreed to acknowledge its receipt.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2021
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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