<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006328
Report Date: 06/29/2023
Date Signed: 06/29/2023 03:39:06 PM

Document Has Been Signed on 06/29/2023 03:39 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SERENITY CARE HOME IIIFACILITY NUMBER:
306006328
ADMINISTRATOR:SALCEDO, MIRIAMFACILITY TYPE:
735
ADDRESS:1462 KENNETH DRIVETELEPHONE:
(949) 346-6010
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 4CENSUS: 0DATE:
06/29/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Miriam SalcedoTIME COMPLETED:
03:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Dwayne Mason Jr. and Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPAs arrived at the facility and were greeted and granted entry by designated Administrator (AD) Miriam Salcedo. 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 3/8/2023.

Structure:
The facility is a one-story home with three resident bedrooms, one bathroom, living room, kitchen, dining room, sun room, and an attached two car garage. LPAs observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the dining room area. There is a back yard with two exit gates on each side of the house. There is one shaded seating areas in the backyard. LPAs did not observe any obstacles or hazards in the backyard.

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

Toxins:
All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to client and will be stored and locked beneath the kitchen sink.

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.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2023
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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SERENITY CARE HOME III
FACILITY NUMBER: 306006328
VISIT DATE: 06/29/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Resident & Staff Files:
Records will be kept locked in storage cabinet located in the kitchen.

Fire Extinguisher:
All fire extinguishers are fully charged.

Reading Material, Games, Equipment & Materials:
The facility has board game materials that will be kept in a cabinet in the hallway.

Fire clearance:
Was approved by a fire inspector of Orange County Fire Authority on 04/17/2023.

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

Bathrooms:


All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 106.3 degrees Fahrenheit.

Linens & Hygiene Supplies:
A supply of extra linen was stored in the hallway storage.

Emergency Phone Numbers, Exit Plan & Menu:
Posted and available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menu was posted and visible.

Food Service:
There is a supply of 2-day perishable and 7-day of non-perishable food on hand.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023
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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SERENITY CARE HOME III
FACILITY NUMBER: 306006328
VISIT DATE: 06/29/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Appliances:
Gas four 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: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3