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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006338
Report Date: 08/09/2023
Date Signed: 08/09/2023 09:29:25 AM


Document Has Been Signed on 08/09/2023 09:29 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:SERENITY HOME CARE LLCFACILITY NUMBER:
306006338
ADMINISTRATOR:WINTERS, ANNETTEFACILITY TYPE:
740
ADDRESS:5582 LIME AVETELEPHONE:
(562) 745-4328
CITY:CYPRESSSTATE: CAZIP CODE:
90630
CAPACITY:6CENSUS: DATE:
08/09/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:36 AM
MET WITH:Annette Winters - AdministratorTIME COMPLETED:
09:40 AM
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On July 27, 2023, following a Pre-Licensing inspection, Licensing Program Analyst, Dwayne Mason Jr. assigned three corrections for Administrator (AD) Annette Winters to complete by close of business (COB) August 28, 2023 in order to be ready for licensure.

LPA returned to the facility on August 9, 2023 and was granted entry to the facility by the AD at 8:30am. LPA discussed with the AD the purpose of the visit.

LPA is conducting a follow-up Pre-Licensing visit with the purpose of verifying the following corrections:

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

Upon inspection, LPA observed that:

1. Closet doors in Resident Bedrooms were replaced with appropriately functional doors.

2. The garage window with a hole in it was replaced with a new window

3. Hot water dispensed in the bathrooms measured between 105 and 120 degrees Fahrenheit. Hot water measured at 115.7 degrees Fahrenheit in the bathroom between the Master Bedroom and Bedroom 2. Hot water measured at 116.4 degrees Fahrenheit in the Master Bathroom.

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.

SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2023
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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