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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006315
Report Date: 07/15/2024
Date Signed: 07/15/2024 03:26:38 PM

Document Has Been Signed on 07/15/2024 03:26 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: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:
07/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Alvin Mendoza, AD via phoneTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct a Case Management Incident Report follow-up. LPA was greeted and granted entry by Danilo Ramos, Direct Support Professional (DSP). During today’s visit, LPA spoke with Alvin Mendoza, Administrator (AD), via telephone. The AD could not attend this visit.

The facility is a 4C single story building with an approved fire clearance of four ambulatory clients. A covered patio was built and was still under construction after the last annual in May 16, 2024. The facility currently has a census of four clients in care. The clients had just returned from Day Program and the fourth client had just returned from a weekend outing with family.

During today’s visit, LPA observed medication storage and reviewed the centrally stored medications. Per review medication appear to be being given as prescribed for all clients. Physician orders were given for vitamins for Client #3 (C3). AD will send LPA via email, proof of staff medication training conducted on July 2, 2024.

LPA reviewed two of four staff training and fingerprint records and reviewed three client records. LPA interviewed alert clients regarding their quality of care and spoke to staff present regarding care provided.

Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Mayela San Millan, Caregiver and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2024
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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