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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005298
Report Date:
08/01/2024
Date Signed:
08/01/2024 02:29:55 PM
Document Has Been Signed on
08/01/2024 02:29 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:
08/01/2024
TYPE OF VISIT:
POC
UNANNOUNCED
TIME BEGAN:
01:18 PM
MET WITH:
Minerva Sansano
TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced Plan of Correction (POC) visit to follow up on deficiencies cited on 07/22/2024. LPA was greeted and granted entry into the facility and explained the reason for the visit. Administrator/ Licensee Minerva Sansano arrived during the visit.
Deficiency cited under Title 22 Regulation 87465(h)(2) pertaining to Centrally Stored Medications has been cleared. Facility has discontinued pre-pouring medications and LPA observed medications in their original containers. Licensee has complied with the POC.
Advisory note given 07/22/2024 indicated the following:
Facility was checking blood pressure for medication administration. Facility has discontinued the practice.
Exit gate appears broken. Facility has repaired gate.
One out of six residents was missing an updated physician report. Facility has obtained updated physician report.
Facility has been advised to remain in compliance with all items cited.
Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME:
Alisa Ortiz
TELEPHONE:
(714) 703-2855
LICENSING EVALUATOR NAME:
Kimberly Lyman
TELEPHONE:
(714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE:
08/01/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/01/2024
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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