306006338-7-27-2023-22-AS-DLMN-CU5VQJ-20230727163824

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006338
Report Date: 07/27/2023
Date Signed: 07/27/2023 04:38:53 PM

Document Has Been Signed on 07/27/2023 04:38 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 HOME CARE LLC		FACILITY NUMBER:	306006338
ADMINISTRATOR:	WINTERS, ANNETTE		FACILITY TYPE:	740
ADDRESS:	5582 LIME AVE		TELEPHONE:	(562) 745-4328
CITY:	CYPRESS	STATE: CA	ZIP CODE:	90630
CAPACITY:	6	CENSUS: 0	DATE:	07/27/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Annette Winters - Administrator		TIME COMPLETED:	11:55 AM

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 Analyst (LPA) Dwayne Mason Jr. made an announced inspection to the facility for purpose of conducting a pre-licensing inspection. LPA arrived at the facility at 9:05am and was greeted and granted entry by designated Administrator (AD) Annette Winters. An application to operate a Residential Care Facility for Elderly (RCFE) for (6) capacity, (0) ambulatory, (6) non-ambulatory, and (0) bedridden clients was received by Community Care Licensing (CCL) on 3/22/2023. Structure: The facility is a one-story home with three resident bedrooms, two bathrooms, living room, kitchen, dining room, family room, an attached two car garage, backyard, porch and a crawl-space accessible through a pull-down ladder in the hallway. Photos of the pull-down ladder leading to the crawl-space were taken. LPA observed the crawl-space to be empty. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in one of the living room. There is a back yard with one exit gate on Northeast side of the house. There is one shaded seating area in the backyard. LPA did not observe any obstacles or hazards in the backyard. LPA observed a hole in one of the garage windows facing the backyard. Applicant must replace this window by the assigned due date in order to be ready for licensing. Client Bedrooms: All resident bedrooms had the required furnishings. LPAs observed all resident beds had linens and blankets. LPA observed all windows were screened. LPA observed closet doors in all resident rooms to be inoperable. The applicant will replace all closet doors by the assigned due date in order to be ready for licensing. Toxins: LPA observed chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to client and will be stored and locked in closet in the hallway. Medications, First-Aid Kit & Book: Medication will be stored in a locked closet in the hallway. First aid kit is stored in the same locked closet. The first aid kit has all the required elements.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L Mason	TELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SERENITY HOME CARE LLC	FACILITY NUMBER: 306006338
	VISIT DATE: 07/27/2023

NARRATIVE

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Resident & Staff Files: Records will be kept locked in the closet in the hallway.

Fire Extinguisher: LPA observed the fire extinguisher to be fully charged as indicated by the arrow pointing in the green zone. LPA observed a receipt of purchase for the fire extinguisher which indicates the fire extinguisher was purchased on 2/27/23.

Reading Material, Games, Equipment & Materials: The facility has activity materials that will be kept on in the living room and family room. Materials for resident use include puzzles, card games, other games and books.

Fire clearance: Was approved by a fire inspector of Orange County Fire Authority on 06/20/2023.

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 122 degrees Fahrenheit in the bathroom between the Master Bedroom and Bedroom 2. Hot water measured at 121.5 degrees Fahrenheit in the Master Bathroom. The applicant must have the water temperature adjusted to between 105 and 120 degrees Fahrenheit by the assigned due date in order to be ready for licensing.

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

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

Food Service: There is a supply of 2-day perishable and 7-day of non-perishable food on hand.

Smoke Detectors: Smoke detectors were observed to be dual Smoke & Carbon Monoxide detectors that are stationed throughout the home. The dual detectors were tested and observed to be operational.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L Mason	TELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SERENITY HOME CARE LLC	FACILITY NUMBER: 306006338
	VISIT DATE: 07/27/2023

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Appliances: Gas five burner stove with 1 oven, 1 refrigerator, dish washer, microwave, washer, and dryer are operational.

The following corrections are needed before applicant is ready for license:

1. Closet doors in Resident Bedrooms must be replaced with appropriately functional doors.

2. The garage window with a hole in it needs to be replaced.

3. Hot water dispensed in the bathrooms must measure between 105 and 120 degrees Fahrenheit

The due date for these corrections are Monday, August 28, 2023 by close of business (COB)

Exit interview was conducted and a copy of this report was provided to designated AD.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L Mason	TELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

LIC809 (FAS) - (06/04)

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