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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006210
Report Date: 10/21/2022
Date Signed: 10/21/2022 02:54:28 PM

Document Has Been Signed on 10/21/2022 02:54 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 HOME IIFACILITY NUMBER:
306006210
ADMINISTRATOR:SALCEDO, MIRIAMFACILITY TYPE:
735
ADDRESS:14121 CARFAX AVETELEPHONE:
(949) 346-6010
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 6CENSUS: 0DATE:
10/21/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Miriam Salcedo- Licensee/Administrator TIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Andrea Mendivil made an announced visit to conduct a pre-licensing inspection. LPA identified themselves and discussed the purpose of the visit with Licensee Miriam Salcedo. An initial application to operate an Adult Residential Facility was received by CCL on 07/05/2022 for a capacity of six ambulatory clients. Facility has a screening area in the entrance of the facility.
LPA Mendivil along with Licensee toured the facility at 1:05PM and observed the following:
Structure: Facility is a single story, 4 bedroom, 2 bathroom house with an attached garage and a white exterior. The exit gates are unlocked and self latching. Living Room/ Dining Room: Adequate seating is available in the dining room and living room, entrance of facility will be utilized as a meeting room. Living room contains a non-operational fireplace which has a cover. Bedrooms Residents: Rooms # 1 and 2 are single occupancy and rooms # 3 and #4 are double occupancy for clients. All of the rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Bathrooms: Client bathroom has a working toilet/ wash basin. Facility has sanitizer and paper towels in the restrooms. Staff bathroom has a working toilet/wash basin. .Linens & Hygiene Supplies: Facility has bedding and towels for clients in care. Emergency Phone Numbers and Exit Plan: Posted in entrance of facility. Food Service: Licensee has 2 day perishable and 7-day nonperishable foods. Smoke Detectors: Smoke detectors/ carbon monoxide detectors were tested and operational. Fire extinguisher present in entry of facility. Appliances: Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. Toxins/ Sharps: LPA observed a secure area for sharps and toxins. Water Temperature: LPA tested hot water and it read as following: client bathroom read at 105.5 degrees, staff bathroom read at 106 degrees and kitchen read at 105.2 degrees. Emergency Supplies: LPA observed supply of emergency water and food. Medications, First-Aid Kit & Book: First aid kit observed contained all required items. CONTINUED ON LIC 809C DATED 10/21/2022
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2022
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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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: SERENITY CARE HOME II
FACILITY NUMBER: 306006210
VISIT DATE: 10/21/2022
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Medication is stored in a locked kitchen cabinet. Facility to use a medication administration record. Resident & Staff File: Records are stored in a locked cabinet.. Reading Material, Games, and Equipment: . LPA observed games and books in facility. Backyard: LPA observed 8 chairs for outdoor seating. Fire Clearance: Approved for six ambulatory on 08/09/2022.

Facility is ready to be licensed. Component III completed. Exit interview 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: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
LIC809 (FAS) - (06/04)
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