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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006315
Report Date: 05/05/2023
Date Signed: 05/05/2023 02:49:42 PM

Document Has Been Signed on 05/05/2023 02:49 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:SERIN HOMESFACILITY NUMBER:
306006315
ADMINISTRATOR:MENDOZA, ALVINFACILITY TYPE:
735
ADDRESS:2051 W. DOGWOOD AVE.TELEPHONE:
(714) 261-4530
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 4CENSUS: 0DATE:
05/05/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Alvin Mendoza
Justine Mendoza		TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA arrived at the facility and was greeted and granted entry by designated Administrator (AD) Alvin Mendoza. Staff Justine Mendoza was also present. An application to operate an Adult Residential Facility (ARF) for (4) capacity, (4) ambulatory, (0) non-ambulatory, and (0) bedridden clients was received by CCL on 1/12/2023.

Structure:
The facility is a one-story house with four client bedrooms, two bathrooms, living room, kitchen, dining room, and unattached two car garage. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the living room. There is a back yard with one exit gate on the east side of the house. A shaded seating area in the backyard will be provided for client use. LPA did not observe any obstacles or hazards in the backyard.

Client Bedrooms
All client bedrooms had the required furnishings. LPA observed all client beds had linens and blankets. LPA observed all windows were screened.

Signal system
There is no signal system.

Toxins:
All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients and will be stored and locked in unattached two car garage.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2023
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 3
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: SERIN HOMES
FACILITY NUMBER: 306006315
VISIT DATE: 05/05/2023
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Medications, First-Aid Kit & Book:
Medication will be stored in a locked cabinet. First aid kit is stored with the medication. The first aid kit has all the required elements.

Resident & Staff Files:
Records will be kept locked in storage cabinet located in the dining room.

Pool/Jacuzzi:
No bodies of water were observed.

Fire Extinguisher:
Fire extinguisher is fully charged.

Reading Material, Games, Equipment & Materials:
The facility has games and sensory toys. Additional games and activities will be provided based on client preference. A tablet will also be available upon client request.

Fire clearance:
Was approved by a fire inspector of Anaheim Fire Department on 03/06/2023. No special conditions noted.

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements.

Bedrooms Staff:


There is no staff bedroom.

Bathrooms:
All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 119.0 degrees Fahrenheit..
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: SERIN HOMES
FACILITY NUMBER: 306006315
VISIT DATE: 05/05/2023
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Linens & Hygiene Supplies:
A supply of extra linen was stored in the hallway storage.

Emergency Phone Numbers, Exit Plan & Menu:
Posted and available, means of exiting and emergency phone numbers listed. Food menu was posted and visible.

Food Service:
A supply of 2-day perishable and 7-day of non-perishable food will be maintained on hand.

Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Appliances:
Gas five burner stove with 1 oven, 1 refrigerator, dish washer, microwave, washer, and dryer are operational.

The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. Exit interview was conducted and a copy of this report was provided to designated AD.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023
LIC809 (FAS) - (06/04)
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