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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006210
Report Date: 11/08/2024
Date Signed: 11/08/2024 04:27:03 PM

Document Has Been Signed on 11/08/2024 04:27 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SERENITY CARE HOME IIFACILITY NUMBER:
306006210
ADMINISTRATOR/
DIRECTOR:		SALCEDO, MIRIAMFACILITY TYPE:
735
ADDRESS:14121 CARFAX AVETELEPHONE:
(949) 346-6010
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 6CENSUS: 4DATE:
11/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Maria OlveraTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) William Vanegas, Samer Haddadin, and Licensing Program Manager (LPM) Alisa Ortiz made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPAs and LPM were greeted and granted entry by staff member Maria Olvera. LPA met with Joanna Acting Administrator (AD) and explained the purpose of the inspection.

LPA reviewed criminal background clearances for facility and was able to locate clearance for individuals Maria Olvera and Joanna Navarro. During the inspection, LPAs, LPM and acting AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following:

This is a one-story home with four resident bedrooms, two bathrooms, one of which is a private staff bathroom, and attached two-car garage. Two out of four client bedrooms had the required furnishings. Two client bedrooms did not have a chair, however acting AD stated that they requested to remove the chairs. LPA observed all client beds had linens and blankets and they are of good quality meaning, no stains or rips. LPA observed three out of four bedrooms with screened windows one client room had one window that was not screened. The backyard has a sitting area, but no umbrella at the time of the tour, however the umbrella was brought and made available for use while LPA’s and LPM were still on site. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 122.7-124.4 degrees Fahrenheit. Clients have the mental capacity to distinguish the water temperature and AD advised that Licensee ordered caution hot water signs and will post them on the walls near the faucets as soon as they arrive. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Five out of six smoke detectors were tested, and they tested operational, however there are 3 smoke detectors near the inoperable smoke detector. AD was made aware of the inoperable smoke detector. Carbon monoxide detectors tested operational as well. Fire extinguisher was observed to be

CONTINUED on 809C

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
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 10
Document Has Been Signed on 11/08/2024 04:27 PM - It Cannot Be Edited


Created By: William Vanegas On 11/08/2024 at 11:41 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SERENITY CARE HOME II
FACILITY NUMBER: 306006210

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Type B
Section Cited
CCR
85095.5(c)
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the Acting Administrator did not comply with the section cited above. Licensee did not have an infection control plan which is used for the purpose of midigating an outbreak readily available for LPA review which poses a potential health and saftey risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Administrator will send infection control plan to LPA via email, and print it out and have it available for review at the facility. Licensee will send proof of corection via email to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:William Vanegas
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2024


LIC809 (FAS) - (06/04)
Page: 2 of 10
Document Has Been Signed on 11/08/2024 04:27 PM - It Cannot Be Edited


Created By: William Vanegas On 11/08/2024 at 11:41 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SERENITY CARE HOME II
FACILITY NUMBER: 306006210

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087(a)(3)
(3) No room commonly used for other purposes shall be used as a bedroom for any person.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the Acting Administrator did not comply with the section cited above as stated by Acting Administrator night shift staff ocastionally sleeps on the couch while clients are sleeping. Which poses a potential safety risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Administrator will document a conversation that is had with night staff in regard to her sleeping durring her shift. Licensee will provide written proof of correction to LPA via email by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:William Vanegas
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2024


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 11/08/2024 04:27 PM - It Cannot Be Edited


Created By: William Vanegas On 11/08/2024 at 11:41 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SERENITY CARE HOME II
FACILITY NUMBER: 306006210

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the Acting Administrator did not comply with the section cited above. LPA reviewed emergency drill log and noted that the last emergency drill was conducted on 03/17/2024 which poses a potential health and safety risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Acting Administrator will conduct an emergency drill with Administrator upon her return to the facility and document it. Proof of correction will be sent via email to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:William Vanegas
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2024


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 11/08/2024 04:27 PM - It Cannot Be Edited


Created By: William Vanegas On 11/08/2024 at 11:41 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SERENITY CARE HOME II
FACILITY NUMBER: 306006210

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80023(b)
Disaster & Mass Casualty Plan
(b) The plan shall be subject to review by the licensing agency and shall include:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the Acting Administrator did not comply with the section cited above as Disaster & Mass Caualty Plan was not available for review. Which poses a potential health and safety risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Administrator will email the Disaster & Mass Casualty Plan to LPA and print it out and have it available for review in the future. Proof of correction will be sent to LPA vial email by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:William Vanegas
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2024


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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: 11/08/2024
NARRATIVE
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fully charged, but tag was outdated, acting AD stated that they have an appointment scheduled with the O.C fire authority to get an updated tag and evaluation scheduled for November 22nd, 2024. Gas stove, microwave, washer, and dryer were all inspected and observed to be operable. Toxic chemicals, cleaning solutions, and disinfectants were observed to be inaccessible to residents. LPA Vanegas reviewed medication administration and storage. Per LPA Vanegas review medications are stored in a locked cabinet and medications are being administered as physicians order.

LPA Haddadin reviewed four client files, and three staff files. All files for clients and staff are being properly monitored and have the required information and files available for review. Acting AD had emergency drill log available for review, however, there has not been a documented drill since March 17th, 2024. Acting AD did not have emergency and disaster plan available for review. Acting AD did not have infection control plan available for review. LPA interviewed acting AD as she was the only staff available, during staff interview acting AD stated that there is overnight staff, but she does not live here. Acting AD stated that the overnight staff does sleep on the couch while the client’s sleep. LPA Vanegas did not interview clients as there were no clients available for an interview.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024
LIC809 (FAS) - (06/04)
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