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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006433
Report Date: 03/21/2025
Date Signed: 03/21/2025 11:43:07 AM

Document Has Been Signed on 03/21/2025 11:43 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 HOMEFACILITY NUMBER:
306006433
ADMINISTRATOR/
DIRECTOR:		BALANZA, HENRYFACILITY TYPE:
735
ADDRESS:12662 EDIETH DRIVETELEPHONE:
(714) 591-5422
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 4CENSUS: 4DATE:
03/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Henry BalanzaTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by Administrators (AD) Henry Balanza and Merida Balanza. The facility is licensed for 4 ambulatory clients. Currently there are 4 clients living here during today's visit.

At 9:00 AM, LPA Tea reviewed four client files and two staff files. Client files and staff files contained all required documentation. The administrator certificate expires on December 18, 2026.



LPA Tea along with the administrator toured the facility at 10:00 AM. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a one-story home with five client bedrooms, one staff room, and two bathrooms. The facility has a kitchen, dining room, and living room, and a small family room, and garage. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each client comfortably. Client bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Water temperature measured around 115.5 Fahrenheit degrees. Client bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including dressings, bandages, tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit.

LPA observed sharps stored and locked underneath the kitchen sink in a separate container. LPA also observed toxin substances to be secured and locked underneath the kitchen sink. The fire extinguisher in the kitchen is fully charged. The facility’s last fire drill was conducted on March 1, 2025. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating with shade. There is a walking path in the backyard that the administrator constructed for clients to walk and ride their

Continuation of annual report on LIC809C

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2025
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 HOME
FACILITY NUMBER: 306006433
VISIT DATE: 03/21/2025
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bikes on. LPA observed emergency supplies, food, and water in the closet by the front entryway. LPA Tea observed clients leaving for their day programs. The staff provide activities based on client’s personal preference such as playing with Legos and exercises. Weekends the staff take the clients for outings like shopping and going out to eat at restaurants.

At 10:30 AM LPA reviewed medication storage and administration. Medications are stored in a locked filing cabinet in the dining area. Medications are being administered per physician order. P&I Funds were checked and meet department standards. LPA interviewed staff present regarding care provided.



Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with administrator Henry Balanza and a copy of this report LIC809, 809-C, LIC858, LIC859 was read and provided to the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025
LIC809 (FAS) - (06/04)
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