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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005582
Report Date: 04/11/2022
Date Signed: 04/11/2022 12:29:36 PM

Document Has Been Signed on 04/11/2022 12:29 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:SERENE BEHAVIORAL HEALTHFACILITY NUMBER:
306005582
ADMINISTRATOR:KARIMKHANI, VALEH DRFACILITY TYPE:
772
ADDRESS:31471 PASEO DURANTELEPHONE:
(714) 656-8296
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY: 6CENSUS: 4DATE:
04/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:27 AM
MET WITH:Cindie Dunkerson, Peter Gates, Ryan WilliamsTIME COMPLETED:
12:38 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation). LPA was greeted and granted entry by staff. LPA explained the reason for the visit. LPA met with Administrator Cindie Dunkerson, Peter Gates and Ryan Williams were also present. LPA and Administrator, Peter Gates and Ryan Williams toured the facility. Facility is a two story home with 6 bedrooms (1 bedroom is used as an office/meeting room), 3 bathrooms, kitchen, dining room, living room, family room, laundry room, staff office and attached garage. Smoke detectors and carbon monoxide detectors tested operational. LPA observed all medications and sharp objects were kept locked in the staff office and are inaccessible to clients. LPA observed the kitchen is clean and organized. The fireplace in the family room is screened. LPA observed the pool and jacuzzi which is separate from the pool in the backyard are both gated and secured. Both exit gates are operational. No obstacles or hazards observed in the backyard. LPA observed all client bedrooms had the required furnishings. All bathrooms were operational. No obstacles or hazards observed in the facility. LPA consulted with the Administrator concerning continued Covid-19 mitigation practices and reporting requirements. Facility has a mitigation plan that has been approved. No deficiencies observed during the visit. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2022
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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