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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006315
Report Date: 05/16/2024
Date Signed: 05/16/2024 03:14:17 PM

Document Has Been Signed on 05/16/2024 03:14 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/
DIRECTOR:		MENDOZA, ALVINFACILITY TYPE:
735
ADDRESS:2051 W. DOGWOOD AVE.TELEPHONE:
(714) 261-4530
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 4CENSUS: 4DATE:
05/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:03 AM
MET WITH:Florendo Caraoa, Direct Service Provider TIME VISIT/
INSPECTION COMPLETED:
03:20 PM
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 On today's date, Licensing Program Analysts (LPAs) Rosie Quiroz and Michael Tea conducted an unannounced Annual Required-1 year inspection visit. LPAs were granted entry by Directive Service Professional (DSP) DSP Florendo Caraoa. LPA Quiroz called Administrator (AD) Alvin Mendoza to inform him about LPA's unannounced visit. AD Mendoza not able to attend today's visit due to planned appointment.
AD Alvin Mendoza reported being on premises more than 20 hours per week. AD Certificate for Alvin Mendoza expires on 9/17/2024.
This is a leveI 4C Facility licensed for a capacity of four clients, (4) Ambulatory clients providing services to Adult clients with Developmental Disabilities ages 18-59. At 11:23am, LPA Quiroz reviewed whether the following is in compliance: licensee is operating the facility within the conditions and limitations, which are specified on the license, including the capacity limitation.
The facility is a 1 story home. The home consists of: 4 private bedrooms, 2 restrooms for clients and staff , living room, kitchen with dining area, activity room, two car garage and back yard with chairs and table but no shaded area for clients in care. (SEE LIC 809-D)
Between 11:07am-11:50am, LPAs reviewed 3 of 4 staff records, 4 of 4 client records and 4 of 4 Personal & Incidental funds records (P&I). Staff records, clients records and P&I funds were found to be within Title 22 California Code of Regulations (CCR).
At 1:46pm, LPAs along with DSP Caraoa conducted the tour inspection. A tour of the interior and exterior of the facility and physical plant were inspected, including but not limited to testing hot water temperature in client and common bathrooms. The client's bathroom water tested and measured between 75.2-111.5 degrees Fahrenheit. DSP indicated "Hot water doesn't work." This was verified with DSP 1. (SEE LIC 809-D) All smoke detectors, carbon monoxide, were operational and functional.
At 2:46pm, LPA Tea reviewed 3 of 4 client centrally stored medication records. LPAs observed medications are secured in a secured cabinet in activity room area, not accessible to clients in care. 3 of 4 Medication records were found to be within Title 22 CCR. (SEE LIC 9102 TV) CONTINUED ON LIC 809-C PAGE...
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2024
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: SERIN HOMES
FACILITY NUMBER: 306006315
VISIT DATE: 05/16/2024
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CONTINUED... LPAs verified if facility is providing a comfortable temperature due to hot/cold weather condition. Facility has a working centralized heater and air conditioner to use for the cold or hot weather as needed. The temperature inside the facility was recorded to be 71 degrees Fahrenheit.
LPAs reviewed facility telephone; provision of sufficient lighting; exit obstructions, if any; and potential hazards. Poisons, toxic substances, and other dangerous objects were noted to be secured in kitchen cabinet area and inside garage not accessible to clients in care. Kitchen knives were stored and secured in kitchen cabinet, not accessible to clients in care.
On or about 2:00pm while inspecting facility LPAs observed ventilation in the main hallway to be non- operational and non-functional. At 2:05pm, LPAs observed broken toiler paper roll holder to be broken in bathroom near facility entrance. At 2:10pm, LPAs observed excessive amount of dirt on fan in living room area. (SEE LIC 809-D)
The nonskid mats were observed in client restrooms. Operational and functional Washer and Dryer were observed in garage area.
The Outside grounds were inspected during facility tour. LPAs observed fence in backyard area to be unstable with a piece of wood utilized to hold fence from falling. (SEE LIC 809-D)
DSP 1 reported offering the following indoor and outdoor activities at the facility according to weather conditions: "Treadmill, xbox gaming, basketball, neighborhood walks, park outings and joined visits with sister facility.”
Two fire extinguishers observed and fully charged, and last tested on October 16, 2023. DSP reports fire drills are conducted with staff and clients. Last facility fire drill was conducted on April 1, 2024.

Plentiful basic hygiene items and linen supply were available. First Aid KIT and other aide supplies were observed to be stored in secured cabinet in kitchen area. There are no security bars or weapons on the premises.
Based on the observations made during today’s visit, the facility is being cited per Title 22 Division 6 of the California Code of Regulations. (SEE LIC 809-D)

An exit interview was conducted with DSP Caraoa and AD Alvin Mendoza via telephone, and a copy of this report, LIC 809-D, LIC 9102-TV, Appeal rights, LIC 858, LIC 859 were provided at exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/16/2024 03:14 PM - It Cannot Be Edited


Created By: Rosie Quiroz On 05/16/2024 at 02:14 PM
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: SERIN HOMES
FACILITY NUMBER: 306006315

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Buildings and Grounds 80087(a): The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors.
This requirement is not met as evidenced by: On or about 2:00pm while inspecting facility LPAs observed ventilation in the main hallway to be non operational and non functional. LPAs observed broken toiler paper roll holder to be broken. At 1:52pm, LPAs observed fence in backyard area to be unstable utilizing piece of wood to hold up the fence from falling. During today's visit, LPAs tested water temperature in bathroom near facility entrance to be 75.2 degrees F. DSP indicated "Hot water doesn't work." This was verified with DSP 1. LPAs observed excessive amount of dirt on fan in living room area.
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to clients in care.
POC Due Date: 05/23/2024
Plan of Correction
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AD Alvin Mendoza will read and understand CCR 80087(a), repair ventilation in bathroom in main hallway, repair water temperature in bathroom near facility entrance, clearn fan in living room area and provide proof of service repair/date and timeframe repair for fence in back yard area by POC due date of 5/23/2024.

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:Alisa Ortiz
LICENSING EVALUATOR NAME:Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/16/2024 03:14 PM - It Cannot Be Edited


Created By: Rosie Quiroz On 05/16/2024 at 02:25 PM
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: SERIN HOMES
FACILITY NUMBER: 306006315

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087.2(b)
Outdoor Activity Space 85087.2(b): The outdoor activity area shall provide a shaded area, and shall be comfortable and furnished for outdoor use.

This requirement is not met as evidenced by: On or about 2:28pm, LPAs observed a table with chairs on side of yard area, but no shade provided for clients in care.
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to clients in care.
POC Due Date: 05/23/2024
Plan of Correction
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AD will provide proof of shade in outdoor activity area by POC due date of 5/23/2024.
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:Alisa Ortiz
LICENSING EVALUATOR NAME:Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024


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