306005814-7-13-2020-22-AS-PVEZ-BRGQAZ-20200713120046

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005814
Report Date: 07/13/2020
Date Signed: 07/13/2020 12:00:53 PM

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 SERENE SENIOR LIVING 2		FACILITY NUMBER:	306005814
ADMINISTRATOR:	SANSANO, MINERVA		FACILITY TYPE:	740
ADDRESS:	24891 BRANCH AVE.		TELEPHONE:	(949) 295-6854
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	6	CENSUS: 6	DATE:	07/13/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Minerva Sansano - Administrator		TIME COMPLETED:	12:00 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) Patricia Velazquez conducted an announced Pre-Licensing visit with Component III Orientation via phone FaceTime virtual technology to A Serene Senior Living 2 due to the Coronavirus Pandemic and precautionary measures. LPA Velazquez conducted the visit with Administrator Minerva Sansano. An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to the Central Applications Bureau (CAB) on 03/23/2020 for a capacity of 6 non-ambulatory residents of which 1 may be bedridden. LPA Velazquez along with Administrator Sansano observed the following: Structure: Facility is a two story house with 4 resident bedrooms, 2 bathrooms, living room, dining area, and kitchen. Upstairs there are 2 staff bedrooms with 1 bathroom. The facility has a white stucco exterior with brick and blue trim. There is an attached 2 car garage that houses the washer and dryer. There is a front yard comprised of a grassy area with plantars as well as a concrete area. The backyard has a shaded concrete area with seating for residents. There are additional flower beds, plantar boxes and trees in the back and side yards. The exit gates on the exterior of the home have self-closing and self-latching mechanisms but one did not self-latch. Signal System: The facility's central heating and air conditioning is controlled by a thermostat located in a hallway. All exit doors were equipped with an auditory alarm and were noted to be in operating condition. Residents are equipped with a call button to summon staff when necessary. Bedrooms Residents: All bedrooms accommodate non-ambulatory residents with bedroom #3 designated for a bedridden resident. Emergency lighting and night lights were not present in the facility. The resident bedrooms accommodate residents' furnishings such as a bed, lamp, night stand, dresser drawers and a closet.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (714) 380-0440
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2020

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 3

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 SERENE SENIOR LIVING 2	FACILITY NUMBER: 306005814
	VISIT DATE: 07/13/2020

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

Bathrooms:
All bathrooms have a working toilet and wash basin with 2 bathrooms containing a walk-in shower. Grab bars were present as a well as a non-skid mat in one bathroom.
Linens and Hygiene Supplies:
Adequate supply of linens are stored in each resident bedroom. The hygiene supplies and additional linen supplies were stored in a linen closet located in a hallway.
Emergency Phone Numbers, Exit Plan:
Readily available for review in the entry way with a facility sketch and exit plan.
Postings:
The Ombudsman and Complaint posters were present and posted on a wall in the entry hallway of the home. Coronavirus (COVID-19) postings were observed throughout the facility.
Food Service and Menu:
There was an adequate supply of 7 day non-perishable and 2 day perishables present in the facility. The sample menu was available for review. Additional food supplies will be located in the garage.
Smoke and Carbon Monoxide Detectors:
Smoke and carbon monoxide alert systems are wireless, were tested and found operational.
Fire Extinguisher:
Fully charged and mounted on a wall in the kitchen and another one mounted on a wall just outside of the kitchen.
Fire Clearance:
Approved on 06/22/2020 for 5 non-ambulatory residents with 1 bedridden resident.
Appliances:
Gas four burner stove with overhead fan and light, single oven, refrigerator/freezer, microwave, and dishwasher. Three of the four stove top burners were inoperable with excessive rust/grease stains noted. The oven and oven racks had excessive black grease stains present. The washer and dryer are located in the garage and noted to be in operating condition.
Toxins and Sharps:
Locked and stored in a locked cabinet located in the garage. The knives and other sharp items are stored in a locked kitchen cabinet.
Water Temperature:
Tested at 110.2 degrees F in bathroom #1 and at 120.6 degrees F in bathroom #2.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (714) 380-0440
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2020

LIC809 (FAS) - (06/04)

Page: 2 of 3

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 SERENE SENIOR LIVING 2	FACILITY NUMBER: 306005814
	VISIT DATE: 07/13/2020

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

Medications, First Aid Kit & Manual:
First Aid kit is stored along with the records in a cabinet located in the living room The facility did not have a First Aid manual present. Resident medications were located in a locked kitchen cabinet.
Resident and Staff Files:
Resident and staff records were kept in a separate cabinet located in the living room.
Reading Material, Games, Equipment, & Materials:
The facility had materials, games, and equipment present in accordance with their plan of operation.
Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance.

The following items need to be addressed prior to licensure:

Complaint poster in the correct size, 20 by 26 inches
First Aid manual
Ensure one bathroom sink properly drains and does not fill up with water
Adjust water temperature to ensure water temperature is not above 120 degrees F
Repair the inoperable stove top burners and remove excessive grease stains surrounding burners
Remove the excessive grease stains in the oven and oven racks
Obtain an additional resident chair for patio seating
Ensure front exit gate is properly self-latching
Obtain emergency lighting and night lights
Obtain emergency supplies
Obtain a non-skid mat for the one bathroom

Facility does not appear ready for licensure. Any items noted during today’s visit are to be corrected by July 30, 2020. LPA Velazquez will conduct a subsequent phone FaceTime Pre-Licensing visit to review the items listed above. An exit phone interview was conducted with Administrator Minerva Sansano and a copy of this report was signed by LPA Patricia Velazquez. This report will be sent via email to Administrator Minerva Sansano who agrees to sign and date the report. This report was sent via email and an electronic read receipt confirms receiving the report. Ms. Sansano agrees to send the original report by mail to the CCLD Regional Office (RO) in Orange. LPA Velazquez provided the RO address to Administrator Minerva Sansano.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (714) 380-0440
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2020

LIC809 (FAS) - (06/04)

Page: 3 of 3