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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004315
Report Date: 04/29/2021
Date Signed: 06/01/2021 04:48:57 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: 4DATE:
04/29/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:32 PM
MET WITH:Dianna ManaloTIME COMPLETED:
01:13 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre conducted a Facetime virtual visit via iPhone, due to Covid-19 pre-cautionary measures.. LPA was greeted and granted entry by Administrator Dianna Manalo. LPA was following up on an SIR reported dated 4/26/2021 for an incident that took place on 4/24/21. Resident (R1) left the facility unassisted and was returned by Caregivers from an adjacent RCFE. R1 has left his home facility and walked down the street and found at the house next door which is another RCFE. R1 was checked and did not require medical assistance. Responsible Party and the primary care physician were notified. R1 was returned to the facility without incident. Facility reported the incident on an SIR and notified LPA by phone about the incident. Based on the information gathered in this visit and the SIR report dated 4/26/21 the following violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SERENITY LIVING
FACILITY NUMBER: 306004315
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/30/2021
Section Cited

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Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) "Care and supervision" means the facility assumes responsibility for, or provides... assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement is not being met as evidenced by:
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Based on the information provided from staff and the SIR, Licensee failed to ensure care and supervision was provided to R1. R1 eloped out of the facility on 04/24/2021 and was found in a neighbor's backyard. This poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2021
LIC809 (FAS) - (06/04)
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