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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006433
Report Date: 03/06/2024
Date Signed: 03/06/2024 12:30:33 PM

Document Has Been Signed on 03/06/2024 12:30 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SERENITY HOMEFACILITY NUMBER:
306006433
ADMINISTRATOR:BALANZA, HENRYFACILITY TYPE:
735
ADDRESS:12662 EDIETH DRIVETELEPHONE:
(714) 591-5422
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 4CENSUS: 4DATE:
03/06/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Henry BalanzaTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Sean Haddad conducted this announced inspection for the purpose of conducting a pre-licensing inspection. LPA met with Applicant (AP) Henry Balanza, discussed the purpose of the inspection, and toured the facility. Facility is to operate an Adult Residential Facility. Application was submitted to Community Care Licensing on 09/22/2023. This is a change of facility type with persons in care. Facility is currently operating as a Group Home. Facility has a granted age exception for 1 under-age client.

During the inspection, LPA and AP observed the following: Structure: this is a one-story home. Facility is a 5-bedroom, 2-bathroom, one-story home with detached garage that is being used for storage. Facility telephone number is (714) 591-5422. Client Bedrooms: the 4 client bedrooms are spacious and will easily accommodate the clients’ furnishings. Lamps, chairs, linens, and storage for each client bedroom inspected. Staff Bedrooms: LPA inspected the 1 staff bedroom. Bathrooms were clean, faucets and toilets were operational. Water temperature: tested at 113 degrees F in the common bathroom near the client rooms and 117.8 in the common bathroom near the kitchen. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: 2 days perishable and 7 days nonperishable food supply reviewed. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the kitchen and garage. Medication cabinet is locked. First-Aid Kit & Activity Supplies: observed and available. Client & Staff Files: LPA reviewed 4 client files and 2 staff files. Fire clearance was approved by Orange County Fire Authority on 11/14/2023. Backyard exit gate is operational and unlocked. Back yard has shaded area for outdoor activities and sufficient seating for clients. Component III was completed with AP during today’s inspection. Facility is currently operating under the liability insurance of current facility SERENITY HOME (306004227). AP will switch liability insurance to new facility once the application is approved. The facility is ready for licensure pending final review of documents.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2024
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SERENITY HOME
FACILITY NUMBER: 306006433
VISIT DATE: 03/06/2024
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During the inspection, LPA explained the process of this application and about the post licensing inspection once the facility is licensed. AP was informed today that the facility is ready for licensure pending final review of documents and final approval will be processed by the CAB supervisor in Sacramento. An exit interview was conducted and a copy of this report was discussed with and provided to AP.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024
LIC809 (FAS) - (06/04)
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