306004685-8-17-2022-22-AS-CDPO-CHDQ7N-20220817115525

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004685
Report Date: 08/17/2022
Date Signed: 08/17/2022 11:55:35 AM

Document Has Been Signed on 08/17/2022 11:55 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:	SERENITY SENIOR CARE HOME		FACILITY NUMBER:	306004685
ADMINISTRATOR:	MINERVA SANSANO		FACILITY TYPE:	740
ADDRESS:	22952 COUNCIL BLUFFS		TELEPHONE:	(949) 600-7757
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	6	CENSUS: 6	DATE:	08/17/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:12 AM
MET WITH:	Facility Administrator - Minerva Sansano		TIME COMPLETED:	12:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required annual inspection focusing primarily on the Infection Control. LPA De Perio explained reason for visit and was greeted and granted entry by staff on duty who checked temperature prior to entering facility. During the visit, there were 2 staff on duty, who contacted facility administrator (AD) Minerva Sansano about visit. As of 8/17/22, there are 0 active COVID-19 cases in the facility as verified. LPA De Perio observed the COVID-19 precautionary signs posted at the main entrance of the facility. The PUB475 "See Something, Say Something" poster was also observed at the entrance of the facility. LPA observed the Administrator's Certificate for Minerva Sansano, which expired on 4/9/22, however AD Sansano conducted a 3 way call with LPA De Perio on 8/16/22 with Sacramento-Community Care Licensing Division Administrator Certification Section representative Roshita Kumar who verified that AD Sansano requested for a renewal and certificate is pending. NOTE: AD Sansano is the administrator for the following facilities: A Serene Senior Living (306005298) A Serene Senior Living 2 (306005814) Serenity Senior Care Home (306004685) Reliance Senior Home (306005762) LPA De Perio toured the interior and exterior portions of the facility with AD Sansano. The facility is a single level structure and is licensed for 6 non-ambulatory residents of which 1 may be bedridden and 4 may be on hospice . For this visit, there are a total of 6 residents in care, 2 on hospice, and 1 bedridden. All 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. The 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 at 107.2 degrees Fahrenheit and hand washing signs were also posted in each restroom.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022

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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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 SENIOR CARE HOME	FACILITY NUMBER: 306004685
	VISIT DATE: 08/17/2022

NARRATIVE

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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 by the dining table.

LPA De Perio observed the emergency disaster and evacuation plan, which is posted at the entrance of the facility. Facility had back-up emergency food and water supply, located in the garage. LPA De Perio observed that First Aid Kit had all the required components. The facility had an adequate supply of PPE that was located in the garage. Medications were locked and inaccessible to residents in care. Toxins were also observed to be locked and inaccessible to residents.

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, of which both were self-closing and self-latching. No bodies of water were observed.

LPA De Perio verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with AD Sansano. LPA De Perio discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

LPA De Perio discussed with AD Sansano to review, print and subscribe for emails regarding the Provider Information Notices (PINs) as well as to attend the CCLD Informational Calls to ensure that facility and staff are up to date. The PINs can be accessed at: www.ccld.ca.gov.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022

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 SENIOR CARE HOME	FACILITY NUMBER: 306004685
	VISIT DATE: 08/17/2022

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

LPA De Perio advised AD Sansano to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

LPA De Perio conducted an exit interview with AD Sansano and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022

LIC809 (FAS) - (06/04)

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