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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005761
Report Date: 10/30/2024
Date Signed: 10/30/2024 11:54:12 AM

Document Has Been Signed on 10/30/2024 11:54 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:TOUCH OF SERENITY SENIOR CAREFACILITY NUMBER:
306005761
ADMINISTRATOR/
DIRECTOR:		REYES, NAYEHYFACILITY TYPE:
740
ADDRESS:24511 SATURNA DRIVETELEPHONE:
(949) 633-5336
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
10/30/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Juan Reyes- AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose of conducting the health and safety case management visit to follow up on the death regarding Resident #1 (R1). LPA was greeted and granted entry after stating the purpose to Caregivers Javier Tamayo and Paloma Alonza. Administrator (Admin) Juan Reyes arrived shortly after.

On October 29, 2024, the Department received the death report of R1. Administrator to forward a copy of the Coroner's Report and Death Certificate once obtained.

LPA toured the facility with Administrator Juan Reyes. Facility was observed to be clean, sanitary, and in good repair. Facility maintains sufficient 2-day supply of perishable and a 7-day supply of non-perishable food. Toxins, medications, and sharps were secured and inaccessible to the residents. The certificate of liability insurance remains current. No health and safety violations were observed during the tour. LPA reviewed and took photographs of R1's pertinent documentation. Admin to forward copies of the following records to LPA via email by end of today's business day: Resident Roster, Death Report, Identification and Emergency Information, Physician's Report, Discharge Summary, Preplacement Appraisal Information, Assessment Form, Needs and Services Plan and Mortuary Information.

Based on the review of the Guardian Employee Roster dated October 30, 2024, S1 and S2 were not associated to the facility at the time of inspection. Admin to submit a copy of S1's and S2's identification cards along with the completed Criminal Background Clearance Transfer Request Forms (LIC9182) by October 31, 2024.

Based on today's visit, a deficiency is being cited, and an immediate civil penalty is being assessed. An exit interview was conducted with Administrator Juan Reyes, and a copy of this report including the LIC809-D, LIC421BG, LIC811s, and the appeal rights were provided at exit.
Lourdes MontoyaTELEPHONE: (714) -70-2870
Jessica ChoTELEPHONE: 714-703-2853
DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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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Document Has Been Signed on 10/30/2024 11:54 AM - 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: TOUCH OF SERENITY SENIOR CARE
FACILITY NUMBER: 306005761

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2024
Section Cited
CCR
87355(e)(2)

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87355 Crmininal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code... shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance... This requirement was not met as evidenced by:
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Adminstrator stated that a copy of the identification cards and LIC9182s will be submitted in addition to an Acknowledgement of Understanding of the said regulation to LPA via email by POC due date.
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Based on observations, interviews, and record review, S1 and S2 were not associated at the time of inspection which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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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: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2024
LIC809 (FAS) - (06/04)
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