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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005761
Report Date: 06/23/2022
Date Signed: 06/23/2022 11:11:58 AM


Document Has Been Signed on 06/23/2022 11:11 AM - 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:TOUCH OF SERENITY SENIOR CAREFACILITY NUMBER:
306005761
ADMINISTRATOR:REYES, NAYEHYFACILITY TYPE:
740
ADDRESS:24511 SATURNA DRIVETELEPHONE:
(949) 633-5336
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
06/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Juan ReyesTIME COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced required annual inspection focusing primarily on the Infection Control. At 10:13 am, LPA was greeted and granted entry by Caregiver Rosa Daniela Gonzalez followed by the Administrator (Admin) Juan Reyes after completing the Coronavirus 2019 (COVID-19) screening procedure. LPA stated the purpose of the visit. As of today, there are no active COVID-19 cases in the facility. Facility screens and documents temperature for all visitors on a sign in sheet. LPA observed the required COVID-19 precautionary signs posted on the door of the main entrance and the entry way. The PUB475 See Something, Say Something poster was observed in the entry way in the size of 20"x26." The Administrator's Certificate expires on 12/02/2022.

Around 10:20 am, LPA toured the interior and exterior portions of the facility with the Admin. The facility is a single level structure and licensed for six non-ambulatory residents; and has a hospice waiver for two. Currently, there a total of five residents in the facility of which one is in hospice care. Facility appeared clean and sanitary in all areas observed. All bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke, carbon monoxides, and auditory exit alarms tested operational. The restrooms were observed to be in good repair; and provided with grab bars and non-skid floor mats. Hot water measured at 129.9 degrees Fahrenheit in Restroom #1; 129.7 degrees Fahrenheit in Restroom #3; 129.5 degrees Fahrenheit in Restroom #4, and Restroom #2 was not measured due to family visiting the resident. The water temperature gauge was adjusted during the visit. LPA observed hand washing signs, paper towels, and hand soaps in the three restrooms. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medications, cleaning supplies, and sharp items were inaccessible to the residents in care. The fire extinguisher was charged and mounted in the kitchen. For the exterior portion, LPA observed patio furniture under a gazebo, and the grounds were free of tripping hazards. The side gates were self-closing and self-latching.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
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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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: TOUCH OF SERENITY SENIOR CARE
FACILITY NUMBER: 306005761
VISIT DATE: 06/23/2022
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LPA reviewed the Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC610E). Facility has a plan for COVID-19 testing residents and staff as well as a plan for isolation as needed. Facility had back-up emergency food and water supply stored in a bin located in the garage. The First Aid Kit had all the required components, and the facility had sufficient PPEs and incontinence supplies also stored in the garage.

LPA discussed Assembly Bill 665 that requires a licensee of any adult or senior care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use. Residents have access to a smart phone upon request.



LPA consulted the following: To maintain the hot water temperature between the ranges of 105 to 120 degrees Fahrenheit.

LPA reviewed the COVID-19 mitigation plan of the facility. No deficiency cited in this review as per Title 22 Division 6 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit, and the licensee will follow-up with the correction. An exit interview was conducted with Administrator Juan Reyes, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
LIC809 (FAS) - (06/04)
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