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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005833
Report Date: 06/21/2022
Date Signed: 06/21/2022 12:35:01 PM

Document Has Been Signed on 06/21/2022 12:35 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:SERENITY CARE HOMEFACILITY NUMBER:
306005833
ADMINISTRATOR:SALCEDO, MIRIAMFACILITY TYPE:
735
ADDRESS:13552 UTT DRIVETELEPHONE:
(714) 617-5883
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 6CENSUS: 4DATE:
06/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:04 AM
MET WITH:Irma Dietz- Caregiver TIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and granted entry into facility by Caregiver Irma Dietz and explained the reason for the visit. Administrator Miriam Salcedo arrived at 11:14 AM.

At 11:05 AM, LPA toured facility with Caregiver Irma Dietz. Facility has 3 clients present during today’s visit. Facility is a 4 bedroom, 2 bathroom, single story home with an attached garage. LPA observed a screening and sanitizing station at entrance of the facility. LPA observed clients relaxing in the facility or in their respective rooms. Facility appears clean and sanitary. All clients rooms had required elements, including bed, chair, closet space and ample lighting. Restrooms are stocked with soap and paper towels and have hand washing postings. Facility has 2 refrigerators with ample food supply. LPA observed facility has emergency food and water supply. Facility has a secured location for client medication and files. LPA toured the outside grounds and observed outside visitation area. Exit gate was locked with a lock requiring a key. Facility has a plan for covid testing clients and staff as needed as well as a plan for isolation. LPA observed a 4 weeks supply of PPE. LPA reviewed all client files and all contained required documentation including updated emergency information. All staff and clients are fully vaccinated for Covid 19.

LPA consulted with Administrator Miriam Salcedo regarding other options to use in lieu of lock on exit gate.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2022
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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