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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005814
Report Date: 08/16/2022
Date Signed: 08/16/2022 11:29:56 AM


Document Has Been Signed on 08/16/2022 11:29 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
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: 6DATE:
08/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:Staff on Duty - Alfred PamintuanTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required annual inspection focusing primarily on the Infection Control. LPA De Perio was greeted and granted entry by staff on duty who checked temperature prior to entering facility. During the visit, 2 staff were on duty, who contacted facility administrator (AD) Minerva Sansano about visit. AD Sansano was unable to be present during time of visit, however provided consent for staff on duty (S1) Alfred Pamintuan to conduct tour, receive and sign report. As of 8/16/22, there are 0 active COVID-19 cases in the facility as verified. LPA De Perio observed the COVID-19 precautionary signs posted at the entrance of the facility. The PUB475 "See Something, Say Something" poster was also observed at the entrance of the facility. LPA De Perio observed the Administrator's Certificate for Minerva Sansano , which expires on 4/9/22, however, AD Sansano conducted a 3 way call with LPA De Perio and Sacramento-Community Care Licensing Division Administrator Certification Section representative Roshita Kumar who verified that AD Sansano requested for a renewal and certificate is pending.

LPA De Perio toured the interior and exterior portions of the facility with S1. The facility is a two level structure. NOTE: Upper level is for staff use and NOT resident use. LPA De Perio verified and observed that there are not residents residing in the second level of the facility. Facility is licensed for residents 60 years of age and older, of which 6 may be non-ambulatory, 1 bedridden and 6 hospice . Currently, there are a total of 6 residents in care, 1 on hospice, 0 bedridden. All bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. The restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured to be at 107.3 degrees Fahrenheit and hand washing signs were also posted in each restroom.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2022
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 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: 08/16/2022
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Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguishers were charged, mounted and located in the kitchen and in the hallway.

For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There is one exit gate in the backyard, which is self-closing and self-latching. Facility had back-up emergency food and water supply, located in the garage.

LPA De Perio observed that First Aid Kit had all the required components. The facility had an adequate supply of PPE located at the entrance of the facility. Medications were locked in a cabinet located in the kitchen. Toxins were also observed to be locked in the garage and inaccessible to residents.

LPA De Perio verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with AD Sansano via phone and S1. LPA De Perio discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. No citations were issued.

LPA De Perio advised AD Sansano to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

LPA De Perio conducted an exit interview with AD Sansano via phone call and S1 and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022
LIC809 (FAS) - (06/04)
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