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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006590
Report Date: 12/20/2024
Date Signed: 12/20/2024 02:40:26 PM

Document Has Been Signed on 12/20/2024 02:40 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 CARE HOME IVFACILITY NUMBER:
306006590
ADMINISTRATOR/
DIRECTOR:		SALCEDO, MIRIAMFACILITY TYPE:
735
ADDRESS:14011 UTT DRTELEPHONE:
(949) 346-6010
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 4CENSUS: 0DATE:
12/20/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Miriam Salcedo - Administrator TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an announced visit to conduct a pre-licensing inspection. LPA identified themselves and discussed the purpose of the visit with Licensee Miriam Salcedo. An initial application to operate an Adult Residential Facility was received by CCL on 05/20/2024 for a capacity of four (4) ambulatory clients.
LPA Mendivil along with Licensee toured the facility at 1:30PM and observed the following:
Structure: Facility is a single story, 4 bedroom, 2 bathroom house with a detached garage and a grey exterior. The exit gates are unlocked and self latching. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Living room contains a non-operational fireplace which has a cover. Bedrooms Residents: All bedrooms are single occupancy. All of the rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Bathrooms: Client bathroom has a working toilet/ wash basin. Linens & Hygiene Supplies: Facility has bedding and towels for clients in care. Emergency Phone Numbers and Exit Plan: Posted in entrance of facility. Food Service: Licensee has 2 day perishable and 7-day nonperishable foods. Smoke Detectors: Smoke detectors/ carbon monoxide detectors were tested and operational. Fire extinguisher present in entry of facility. Appliances: Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. Toxins/ Sharps: LPA observed a secure area for sharps and toxins. Water Temperature: LPA tested hot water and it read as following: client bathroom read at 108.2 and 109.6 in dual sinks, master bathroom sink read at 111.9 degrees and kitchen read at 106.4 degrees. Emergency Supplies: LPA observed supply of emergency water and food. Medications, LPA observed a locked cabinet in the kitchen for medication. Facility to use a medication administration record. First-Aid Kit & Book: First aid kit observed contained all required items. CONTINUED ON LIC 809C DATED 12/20/2024
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2024
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 CARE HOME IV
FACILITY NUMBER: 306006590
VISIT DATE: 12/20/2024
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 Resident & Staff File: Records are stored in a locked cabinet. Reading Material, Games, and Equipment: . LPA observed games and books in facility. Backyard: LPA observed a shaded area for clients to sit. Fire Clearance: Approved for 4 ambulatory on 07/02/2024.

Facility is ready to be licensed. Component III completed. Exit interview conducted and a copy of this report was provided to Licensee.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
LIC809 (FAS) - (06/04)
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