306005803-10-25-2022-22-AS-JHAY-CKJS9J-20221025134049

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005803
Report Date: 10/25/2022
Date Signed: 10/25/2022 01:41:41 PM

Document Has Been Signed on 10/25/2022 01:41 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 TOUCH OF SERENITY RESIDENTIAL CARE		FACILITY NUMBER:	306005803
ADMINISTRATOR:	JUAN REYES		FACILITY TYPE:	740
ADDRESS:	24562 ARTEMIA AVE		TELEPHONE:	(949) 633-5336
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 5	DATE:	10/25/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:05 PM
MET WITH:	Juan Reyes		TIME COMPLETED:	01:50 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by staff and explained the reason for the visit. Staff called the Director/Administrator (AD) Juan Reyes via telephone who arrived and was present for the visit. AD Reyes has a current administrators certificate that expires 12/02/22.

At 12:25 PM LPA Haley began the tour of the facility with AD Reyes. There were five residents present for the visit. Right near the entrance of the facility there is a COVID screening station with temperature log books, a thermometer, gloves and hand sanitizer. Right near the entrance of the living room, there's a locked closet with staff files, resident files, and medication.

All client bedrooms were clean, well organized, and had all necessary requirements: night stand, chair, lamp and storage space. All bedroom exit alarms were functional. Both client bathrooms were clean and very well organized.

The kitchen was clean and organized. All knives and sharp objects were locked under the sink. Hazardous chemicals were also locked under the sink. All burners on the stove were operational. The facility has a two day supply of perishable food items and seven day supply of nonperishable food items. LPA observed a first aid kit with all required elements in a cabinet near the refrigerator. There is a fully charged fire extinguisher mounted on the wall near the refrigerator. LPA also observed a locked cabinet under the kitchen counter that's used to store resident medication.

In between the kitchen and the garage there is a laundry room that remains locked. In the laundry room there is a closet that is used by staff for their miscellaneous items. Cleaning supplies are kept in the cabinets above the washer and dryer.

Continued on LIC809C Dated October 25, 2022

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: A TOUCH OF SERENITY RESIDENTIAL CARE	FACILITY NUMBER: 306005803
	VISIT DATE: 10/25/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The garage was clean and organized. Walkways were clear of obstruction and tripping hazards. In the garage LPA Haley observed additional supplies and items: mattresses, chairs, and a dresser to name a few of the items. There is a refridgerator in the garage with an additional supply of perishable food items. LPA Haley observed an emergency container equipped with emergency food, water, and emergency COVID PPE supplies prepared and ready to go. Additional cleaning supplies, and plenty of adult diapers was also observed in the garage.

The backyard was clean, very well organized, and free of clutter. Both side exit gates were alarmed, self closing and self latching. A shaded area with a table and chairs was observed. A pool surrounded by a gate that meets regulation guidelines was observed. LPA Haley advised Director Juan Reyes to exchange the lock currently on the pool gate with a child proof lock and showed a picture for reference. Director Reyes understood and agreeded to replace the lock on the pool with a child proof lock.

All smoke detectors were tested and are operational. No deficiencies are being cited during todays visit. An exit interview conducted and a copy of the report was provided to Director/Administrator Juan Reyes.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2