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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006210
Report Date: 11/15/2023
Date Signed: 11/15/2023 11:34:55 AM

Document Has Been Signed on 11/15/2023 11:34 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
ORANGE COUNTY RO, 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: 4DATE:
11/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Miriam SalcedoTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility was greeted and granted entry by Johana Navarro, staff and LPA explained the nature of the visit. Miriam Salcedo, Administrator arrived shortly after and met with LPA.

Four clients reside at this facility, LPA was informed three clients were out in the community. At the time of visit one client was present at the facility. LPA accompanied with staff began the tour of the inside and outside of the facility. LPA observed required department postings posted on the wall of facility. Facility stays within the capacity limitations. There is a minimum of one week of non-perishables foods and two days of perishables foods available. The facility is maintained at a comfortable temperature. LPA inspected that medication are centrally stored in a safe locked storage cabinet located in kitchen. LPA reviewed medication and observed medication was labeled and stored inaccessible to clients in care. LPA inspected the bathroom and LPA measured the hot water temperature which measured 120 Fahrenheit degrees. All bathrooms observed to have a supply of soap, toilet paper and towels. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored locked underneath kitchen sink and in laundry unit. The facility has an available clean supply of linens. LPA inspected client’s bedrooms which has sufficient lighting to ensure the safety and comfort. All bedrooms observed to have all required components. Storage space is provided for clients in their bedroom. Smoke detectors were tested and found to be operational. LPA toured the outside of the facility and observed outdoor passageways are free of obstructions. LPA observed there is shaded seating areas for client’s enjoyment. LPA observed a fire extinguisher with service date of November 03, 2023 throughout the facility. Fire drills conducted every three months and LPA verified last Fire Drill was conducted
Continued on LIC809-C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2023
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SERENITY CARE HOME II
FACILITY NUMBER: 306006210
VISIT DATE: 11/15/2023
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on August 28, 2023. LPA began review of records. LPA reviewed four clients’ records. All the required documentation was present and current in client’s files reviewed. The facility P&I records were reviewed. LPA observed that an individual log is maintained for each client. All monies are accounted for and attached receipts for record keeping. LPA reviewed two employee records. All employees present have a criminal record clearance and are associated to the facility. LPA observed records reviewed have a current First Aid certificate. LPA as a reminder provided annual fee dues information.

Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with the Administrator and a copy of this report was provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023
LIC809 (FAS) - (06/04)
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