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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004685
Report Date: 08/12/2024
Date Signed: 08/12/2024 06:03:29 PM

Document Has Been Signed on 08/12/2024 06:03 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:SERENITY SENIOR CARE HOMEFACILITY NUMBER:
306004685
ADMINISTRATOR/
DIRECTOR:		MINERVA SANSANOFACILITY TYPE:
740
ADDRESS:22952 COUNCIL BLUFFSTELEPHONE:
(949) 600-7757
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 6DATE:
08/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:25 PM
MET WITH:Minerva SansanoTIME VISIT/
INSPECTION COMPLETED:
06:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator Minerva Sansano and explained the reason for the visit. LPA and the Administrator toured the facility. Facility is a one story home with 5 bedrooms (1 is for staff), living room, dining room, kitchen, 2 bathrooms and an attached 2 car garage. Facility is licensed for a capacity of 6 non-ambulatory residents of which 1 may be bedridden, with a hospice waiver for 4. LPA observed the See Something, Say Something poster (PUB 475) that is posted next to the front door is 8 1/2 by 11 inches in size. LPA observed the fireplace in the living room is screened. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. The kitchen is clean and organized. LPA observed the sharp object and cleaning supplies are kept under the kitchen sink and are inaccessible to residents. LPA observed all resident rooms have the required furnishings and bed linens. Smoke detectors/carbon monoxide detectors tested operational. LPA observed the medication is kept locked in a filing cabinet in the dining room. LPA observed both bathrooms are clean and operational. Hot water measured 106.0 to 106.7 degrees Fahrenheit. LPA inspected the first aid kit. The first aid kit did not have a current edition first aid manual. The fire extinguisher in the kitchen is fully charged. LPA and Administrator toured the garage. LPA observed extra food and supplies stored in the garage including clean bed linens. The garage is used for storage and kept locked. LPA and Administrator toured the backyard. There is a shaded seating area for residents to sit outside. No bodies of water observed. Both exit gates are operational and self closing. No obstacles or hazards observed in the backyard. LPA observed there is no internet device for residents at the facility. The Administrator verified this information. LPA reviewed 2 staff records. Both staff members had the required training. No discrepancies observed in the staff files. LPA reviewed 6 resident files and medication. No medication discrepancies observed. LPA observed Residents 3 and Resident 4 (R3, R4) did not have current physician's reports (LIC 602As) no other discrepancies observed. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report along with appeal rights was provided to the Administrator.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2024
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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Document Has Been Signed on 08/12/2024 06:03 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 08/12/2024 at 05:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SERENITY SENIOR CARE HOME
FACILITY NUMBER: 306004685

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 6 residents (R3 & R4) do not have a current medical assessments (LIC 602A) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2024
Plan of Correction
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Licensee agrees to update R3's and R4's LIC 602A by the poc due date. Licensee to submit proof of correction to the LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Sheila Santos
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024


LIC809 (FAS) - (06/04)
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