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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005814
Report Date: 09/24/2021
Date Signed: 09/24/2021 12:32:30 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 2FACILITY NUMBER:
306005814
ADMINISTRATOR:SANSANO, MINERVAFACILITY TYPE:
740
ADDRESS:24891 BRANCH AVE.TELEPHONE:
(949) 215-1033
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 4DATE:
09/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:32 AM
MET WITH:Alfred Pamintuan, Minerva SansanoTIME COMPLETED:
12:45 PM
NARRATIVE
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting an Annual Inspection. LPA met with Staff member #1 (S1) Alfred Pamintuan and discussed the purpose of the inspection. Administrator (AD) Minerva Sansano arrived during the inspection. During the inspection, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, garage, and kitchen and observed the following:

LPA and AD observed there were 2 staff present. LPA observed 3 residents were present. LPA confirmed all residents were doing well. LPA inspected common areas, resident rooms, garage, and kitchen. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. LPA observed hallways and walkways were free of obstruction.
During the inspection, LPA and AD observed the following: unsecured medications in a cabinet in the kitchen; unsecured toxins and sharps, including cleaning supplies, paint, and knives, in a cabinet and under-sink storage in the kitchen and in multiple areas of the garage. During the inspection, AD properly secured all of these items and LPA confirmed.

LPA reviewed and confirmed facility policies and practices regarding resident screening, staff screening, visitation, COVID-19 surveillance testing, COVID-19 clearance testing, quarantine, isolation, cohorting, staffing, infection control/lead/training, PPE, staffing and staffing shortages, communication and emergency plan, and dementia. LPA provided technical assistance regarding visitation, outings, N95 fit testing, and sanitation. LPA requested and reviewed resident roster, staff roster, staff files, resident files, emergency plan, and COVID-19 mitigation plan.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
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: A SERENE SENIOR LIVING 2
FACILITY NUMBER: 306005814
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)


87303 Maintenance and Operation: (a) The facility shall be clean, safe... This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not ensure prescription medications and over the counter medications were inaccessible to residents in the kitchen, which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/25/2021
Plan of Correction
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Licensee immediately secured the medications and other dangerous items during today's inspection and LPA confirmed.
Type A
Section Cited
CCR
87309(a)


87309 Storage Space: (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not ensure toxins and sharps, including cleaning supplies, paint, and knives, were inaccessible to residents in the kitchen and garage, which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/25/2021
Plan of Correction
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Licensee immediately secured the toxins, sharps, and other dangerous items during today's inspection and LPA confirmed.
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: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2021
LIC809 (FAS) - (06/04)
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