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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006315
Report Date: 04/22/2025
Date Signed: 04/22/2025 02:03:59 PM

Document Has Been Signed on 04/22/2025 02:03 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: 3DATE:
04/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:44 AM
MET WITH:Luis PindaTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit today to perform the Annual Required Inspection. Upon arrival, LPA Haddadin was greeted by care staff member Luis Pinda, who granted access to the facility.

The facility is a one-story home that includes: four private bedrooms, two restrooms for clients and staff, a living room, a kitchen with a dining area, an activity room, and a two-car garage.

During the inspection of the common areas, LPA Haddadin observed operational smoke detectors and carbon monoxide detectors in both the common areas and the bedrooms. Testing confirmed that all detectors were functioning correctly. Client bedrooms were appropriately furnished with beds, linens, and adequate closet/drawer space for each client's comfort. Client bathrooms were also inspected, and all toilets and water faucets were in proper working order. Grab bars were securely installed, and the showers were free of mold and mildew.

Water temperature measurements in the first restroom were recorded at 118.1 degrees Fahrenheit and at 109.8 degrees Fahrenheit in the second restroom. An adequate supply of bath towels and personal hygiene items was available at the time of the visit. Common areas were found to be clean, free of hazards, and doorways were clear of obstructions.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Samer Haddadin
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: SERIN HOMES
FACILITY NUMBER: 306006315
VISIT DATE: 04/22/2025
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The first aid kit contained all required items, including bandages, tweezers, a thermometer, scissors, and a manual. An inspection of the kitchen revealed that all appliances were operational. LPA Haddadin noted that the facility had a two-day supply of perishable food and a seven-day supply of non-perishable food, meeting regulatory requirements. Sharps and knives were observed to be securely locked in a kitchen cabinet. Additionally, toxic substances were found locked and inaccessible to clients in a storage closet located in the garage.

LPA Haddadin reviewed the files of two clients and two staff members. Both client and staff files contained all necessary documentation. The administrator's certificate is valid until December 5, 2025. The facility's most recent fire drill was conducted on March 1, 2025. A tour of the backyard revealed a shaded seating area and ample space for activities.

Based on today's visit, no deficiencies are being cited in accordance with Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was provided to the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Samer Haddadin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
LIC809 (FAS) - (06/04)
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