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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005946
Report Date: 05/27/2021
Date Signed: 05/27/2021 05:16:15 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:SERRA SOLFACILITY NUMBER:
306005946
ADMINISTRATOR:LOPEZ, JANELLEFACILITY TYPE:
740
ADDRESS:31451 AVENIDA LOS CERRITOSTELEPHONE:
(510) 548-6600
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:70CENSUS: 0DATE:
05/27/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Rebecca Langdon, Susan Peterson, Scott GardnerTIME COMPLETED:
05:31 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made this announced visit for the purposes of conducting a Pre-licensing inspection. LPA met with Rebecca Langdon, Susan Peterson and Scott Gardner. Facility is to operate a Residential Care Facility for the elderly. Facility is for residents with Dementia. Capacity is for 70 non-ambulatory residents. Application was submitted to CCL on 12/11/2020. Structure; Facility is a two story building with a central courtyard and surrounding parking lot. No bodies of water observed. LPA inspected all 58 resident rooms, kitchen, dining rooms, laundry room, medication room and theater room. LPA observed that only the two model rooms had furnishings. LPA observed no obstacles or hazards in the facility. Call system is operational. LPA observed a wired smoke/carbon monoxide detector in each room. System tested during Fire inspection. All bathrooms were clean and operational and grab bars were secure. Hot water temperature measured between 114.6 degrees Fahrenheit and 120.0 degrees Fahrenheit. LPA toured the courtyard and outside parking lot, no obstacles or hazards observed. All fire extinguishers were fully charged. LPA observed the emergency chair lift mounted next to the stairway. Facility telephone number is 949-485-2022. Bathrooms, were clean, faucets and toilets were operational. LPA observed that the kitchen was clean and knives are kept secured. First-Aid Kit & Activity Supplies. observed and available. Resident & Staff Files facility has no residents at this time, no files reviewed. Delayed Egress exit doors are operational. Fire clearance was approved by Orange County Fire Authority Inspector Michael Longobard on 05/4/2021. LPA informed applicants that the facility is required to provide furniture to include, bed, nightstand, lamp and chair, in good working order for residents who require it. Applicants stated they understood. Facility meets Title 22 Division 6 of the California Code of Regulations. Facility is ready for licensure. LPA explained the process of this application and also about post licensing visit once the facility is licensed. Applicant was informed today that the final approval will be processed by the CAU supervisor in Sacramento. Component III was completed with applicant. An exit interview was conducted and a copy of this report, LIC809 was explained and provided to Susan Peterson.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
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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