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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006328
Report Date: 07/02/2024
Date Signed: 07/02/2024 11:11:25 AM

Document Has Been Signed on 07/02/2024 11:11 AM - 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:SERENITY CARE HOME IIIFACILITY NUMBER:
306006328
ADMINISTRATOR/
DIRECTOR:		SALCEDO, MIRIAMFACILITY TYPE:
735
ADDRESS:1462 KENNETH DRIVETELEPHONE:
(949) 346-6010
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 4CENSUS: 2DATE:
07/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:02 AM
MET WITH:Miriam SalcedoTIME VISIT/
INSPECTION COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Michael Tea made an unannounced visit to the facility today to conduct an Annual Random/Required Evaluation. At 8:00 AM LPA Tea was greeted and granted entry by Francisco Rodriguez, a caregiver. During today’s visit, LPA met with administrator Miriam Salcedo and the assistant administrator, Joanna Navarro of the facility.

The facility is a single-story building with an approved fire clearance of four ambulatory clients. The facility currently has a census of two clients in care.

Around 8:36 AM LPA reviewed one staff record, two client records. There were discrepancies noted in the review of client files. Administrator certificate expired on January 21, 2024, however administrator has complied with all course work and is pending renewal at this time.

LPA Tea with the assistant administrator Joanna Navarro toured the facility at 9:00 AM. The facility consists of: 3 private resident bedrooms, 1 bathroom, sun room, living-room, kitchen, and garage. During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in the bathrooms. The hot water temperature measured between 110.3 F and all smoke detectors were operational. Common areas were clean and clear of hazards, doorways were free of obstructions. There is a camera placed in the living room of the facility without audio for the safety of clients in care. LPA observed sharp objects locked and secured in a cabinet in the kitchen area and observed toxin substances to be locked and inaccessible to clients in care underneath the kitchen sink and cabinets in the sun room. LPA inspected the facility food supply and observed perishable and non-perishable food supply was checked and adequately stocked at time of visit. Fire extinguisher in the kitchen was fully charged. The facility’s last fire drill was conducted on May 23, 2024.

Continuation of Annual on LIC809-C
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SERENITY CARE HOME III
FACILITY NUMBER: 306006328
VISIT DATE: 07/02/2024
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Kitchen appliances are operational during today's visit. LPA toured the outside grounds, there is a backyard with ample shade and outdoor furniture. There are two self-latching gates on both sides of the house. One is not working, but the administrator has reported to the property owner about the fence and gate issues. The garage has additional food supplies, emergency food and water.

LPA observed medication storage to be secured in a kitchen cabinet and reviewed the centrally stored medications. Per review completed medication appear to be given as prescribed. P&I Funds were reviewed and there were no discrepancies. First aid kit had all the required elements including tweezers, thermometer, and scissors.

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 deficiency cited on this date.

An exit interview was conducted with administrator, Miriam Salcedo and a copy of the report was provided at the time of the visit

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC809 (FAS) - (06/04)
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