<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005814
Report Date: 07/31/2020
Date Signed: 07/31/2020 11:43:52 AM

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 2FACILITY NUMBER:
306005814
ADMINISTRATOR:SANSANO, MINERVAFACILITY TYPE:
740
ADDRESS:24891 BRANCH AVE.TELEPHONE:
(949) 295-6854
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 4DATE:
07/31/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Minerva Sansano - AdministratorTIME COMPLETED:
11:45 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 subsequent Pre-Licensing visit utilizing 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. The purpose of today's subsequent Pre-Licensing visit was to follow-up on the issues that were present during the initial Pre-Licensing visit dated 07/13/2020. The following issues were observed and required correction:
  • 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. Hot water temperature tested at 105.2 degrees F in bathroom 1 and at 105.0 degrees F in bathroom 2.
  • 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

On today's phone FaceTime visit the aforementioned items have been addressed and corrected. The items reviewed during this visit are in compliance. The Pre-Licensing is complete and the facility appears ready for licensure. The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Bureau.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (714) 380-0440
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2020
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 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 SERENE SENIOR LIVING 2
FACILITY NUMBER: 306005814
VISIT DATE: 07/31/2020
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
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 Ms. 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. Administrator Minerva 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 AdamsTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (714) 380-0440
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2020
LIC809 (FAS) - (06/04)
Page: 2 of 2