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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005298
Report Date: 06/29/2021
Date Signed: 06/29/2021 03:34:12 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:A SERENE SENIOR LIVINGFACILITY NUMBER:
306005298
ADMINISTRATOR:SANSANO, MINEVAFACILITY TYPE:
740
ADDRESS:24562 DARDANIA AVETELEPHONE:
(949) 295-6854
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
06/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Administrator Minerva Sansano TIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Albert Marin conducted an unannounced required annual inspection in this facility. LPA met with Administrator (AD) Minerva Sansano and stated the purpose of this visit.

The facility is single level structure licensed for capacity of six non-ambulatory of which one may be bedridden and with hospice waiver for four. For this visit, there were two residents under hospice care.

About 2:35 PM, LPA Marin was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. LPA observed six residents in care and two staff members on the floor. LPA toured the interior and exterior portions of the facility. There were four private and one shared resident’s rooms. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Hardwired smoke, carbon monoxide and auditory exit alarms were tested to be operational. Bathrooms were provided with grab bars; non-skid floor mats, and hot water was taken at 105 degrees Fahrenheit. Facility met the minimum two-day perishable and seven-day non-perishable food stock requirements. Medications, cleaning supplies and sharp items were inaccessible to residents in care. Fire extinguisher was mounted and charged. For the exterior portion of the facility, patio furniture were observed in to be in good repair, and grounds were free of tripping hazards. Exterior exit door was self-closing and self-latching.

LPA Marin reviewed the COVID 19 mitigation plan of the facility.

For this visit, the facility was observed to be in substantial compliance with Title 22 Division 6 of the California Code of Regulations.

LPA Marin conducted an exit interview with AD Sansano LPA left the copy of this report with AD.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
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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