306005298-7-22-2024-22-AS-KLYN-D7ENT7-20240722104417

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005298
Report Date: 07/22/2024
Date Signed: 07/22/2024 03:13:44 PM

Document Has Been Signed on 07/22/2024 03:13 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	A SERENE SENIOR LIVING		FACILITY NUMBER:	306005298
ADMINISTRATOR:	SANSANO, MINEVA		FACILITY TYPE:	740
ADDRESS:	24562 DARDANIA AVE		TELEPHONE:	(949) 295-6854
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 6	DATE:	07/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	07:15 AM
MET WITH:	Raquel Pamintuan		TIME COMPLETED:	11:05 AM

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) Kimberly Lyman conducted an unannounced visit to A Serene Senior Living. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the facility and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents, one of which may be bedridden. Facility has an approved hospice waiver for 4 residents and the home currently has 6 residents, with 2 on hospice. Administrators Minerva Sansano and Ray Santianez arrived during the visit. Administrator Ray Santianez has an administrator certificate valid until 08/18/2025. LPA Lyman along with Caregiver Raquel Pamintuan toured the facility at 7:36 AM. LPA toured the physical plant, checked food service, first aid kit and reviewed records. Facility appears to be clean, safe, and sanitary. The home consists of six resident bedrooms, 2 common restrooms, one staff room, living room, dining room, and kitchen. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. LPA observed five residents with a half bed rails. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 106.8 and 107.7 degrees F in all facility bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. Auditory exit alarms were operational during today's visit. First aid kit had all the elements including thermometer, tweezers and scissors as well as a first aid manual. LPA observed toxins are secured during today's visit. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Smoke detectors and Carbon Monoxide detectors are hardwired and tested operational during today's visit. Fire extinguisher is fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample shaded seating for residents. Exit gates are unlocked and self latching. LPA observed ample emergency food and water supply. LPA reviewed the emergency disaster plan and infection control plan during the visit. Plans are thorough and complete. Facility provided documentation of last fire drill conducted on 04/24/2024. CONT ON LIC809-C DATED 07/21/2024.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024

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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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: A SERENE SENIOR LIVING	FACILITY NUMBER: 306005298
	VISIT DATE: 07/22/2024

NARRATIVE

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Facility provides activities in the form of exercise, games and music. At 8:30 AM, LPA reviewed six resident files and five staff files. Resident files contained required documents including admission agreements, physician reports and resident appraisals. Staff files reviewed contained required documentation of medical clearance/ TB, CPR training and criminal record clearance. Three out of five staff files do not have proof of training in the file. At 9:30 AM, LPA reviewed medication storage and administration. Medications are stored in a locked cabinet. Medications are being administered per physician order. LPA observed facility is pre-pouring medications for 48 hours.

Based on the observations made during today's visit, 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: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 07/22/2024 03:13 PM - It Cannot Be Edited

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: A SERENE SENIOR LIVING	FACILITY NUMBER: 306005298
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA observed facility is prepouring medications for 48 hours. This poses an immediate health and safety risk to persons in care.
	POC Due Date: 07/23/2024
	Plan of Correction
1 2 3 4	Licensee to conduct an in-service on medication administration and forward proof to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 07/22/2024 03:13 PM - It Cannot Be Edited

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: A SERENE SENIOR LIVING	FACILITY NUMBER: 306005298
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(c)

Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in three out of five staff files lacking documented training which poses a potential health and safety risk to persons in care.
	POC Due Date: 08/06/2024
	Plan of Correction
1 2 3 4	Licensee to provide training and maintain in file. Licensee to forward proof to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024

LIC809 (FAS) - (06/04)

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