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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005582
Report Date: 03/14/2023
Date Signed: 03/14/2023 12:36:26 PM

Document Has Been Signed on 03/14/2023 12:36 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 & INLAND A/SC, 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:
03/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:April James,
Catherine Aquino		TIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility was greeted and granted entry by staff. LPA met with April James, Lead Direct Care Staff and explained the nature of the visit. Catherine Aquino, Executive Director arrived shortly after and met with LPA. Four clients currently reside at this location.

At 9:30am LPA accompanied by staff began the tour of the inside and outside of the facility. The facility is a two story home with client’s bedrooms in the second floor. LPA observed a sign-in procedure in place in the main entry of the facility. LPA observed required Department postings throughout the facility. LPA observed that the facility stays within the capacity limitations. There is a minimum of one week of non-perishables food and two days of perishables foods available. There is additional food storage in attached garage in refrigerator and garage pantry. The facility is maintained at a comfortable temperature. The facility has one full bathroom downstairs and at 10:10am LPA measured the hot water temperature which measured 105.1 Fahrenheit degrees. LPA inspected that medication are centrally stored in a safe locked storage closet in medication room. LPA reviewed medication and observed medication was labeled and store inaccessible to clients in care. At 10:40am LPA measured the hot water temperature in the upstairs bathroom which measured 105.6 Fahrenheit degrees. All bathrooms observed to have a supply of soap, toilet paper and paper towels. The facility provides personal hygiene items for clients use. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. The facility has an available a clean supply of linen. LPA toured the second floor of the facility and inspected client’s bedrooms which had sufficient lighting to ensure the safety and comfort. Storage space is provided for clients in their bedroom. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored and locked in garage inaccessible to clients. Smoke detectors and alarms were tested and found to be operational. LPA toured the outside of the parameters of facility and observed outdoor passageways are free of obstruction. LPA observed a swimming pool in the back yard with a

Continued on LIC809-C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2023
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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SERENE BEHAVIORAL HEALTH
FACILITY NUMBER: 306005582
VISIT DATE: 03/14/2023
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fence around it, the fence has a lock for inaccessibility. During the inspection LPA reviewed staff records, four client records and medication records. All employees have a criminal record clearance. During the inspection LPA spoke to available clients.

Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with the facility representative and a copy of this report was provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023
LIC809 (FAS) - (06/04)
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