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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006714
Report Date: 03/11/2025
Date Signed: 03/11/2025 10:29:41 AM

Document Has Been Signed on 03/11/2025 10:29 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SERENITY CARE HOMEFACILITY NUMBER:
306006714
ADMINISTRATOR/
DIRECTOR:		SALCEDO, MIRIAMFACILITY TYPE:
735
ADDRESS:13961 MAUVE DRIVETELEPHONE:
(949) 346-6010
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY: 6CENSUS: 4DATE:
03/11/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:05 AM
MET WITH:Administrator Miriam SalcedoTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Brandon Lopez made an announced visit to the facility for the purpose of conducting a Pre-licensing Inspection. LPA met with Administrator Miriam Salcedo. LPA observed that Administrator Miriam Salcedo has a valid Administrator certificate which expires on January 21, 2026.

An initial application to operate an Adult Residential Facility (ARF) for a capacity of six ambulatory clients was received by Community Care Licensing (CCL) on February 19, 2025. This is a change of location with four clients already in care and who will eventually being relocated from licensed facility #306005833. The facility received an approved Fire Clearance by Orange County Fire Authority Inspector Lexie Anker on March 5, 2025.

The facility is a one story home with five client bedrooms, one of which can be shared, three shared resident bathrooms, a kitchen, a dining room, a living room, a family room, a sun room, a laundry room, an attached two car garage. LPA accompanied by the AD conducted a tour of the interior portion of the facility. LPA observed the See Something, Say Something poster (PUB 475) mounted on the wall in the dining room. LPA inspected the five resident bedrooms. The five resident bedrooms are clean and free of hazards. AD stated that she will relocate all the required furnishings of a bed, a chair, a chest of drawers, and a lamp for each client from the current facility #306005833 to this facility once it is licensed. LPA inspected all three shared resident bathrooms. Resident bathrooms are clean. Faucets and toilets were operational. Hot water temperature measured between 106.7 and 116.4 degrees Fahrenheit.

AD stated that she will relocate all the activity equipment such as reading books, arts and craft supplies, and board games for client use to this facility once it is licensed. AD stated that once the facility is licensed, client and staff records will be relocated and kept in a locked storage cabinet. LPA observed the four top electric stove, the refrigerator, and the microwave to be clean and operational. LPA observed knives and sharps will be stored in a locked kitchen cabinet. CONTINUED ON 809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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 CARE HOME
FACILITY NUMBER: 306006714
VISIT DATE: 03/11/2025
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LPA observed chemicals and toxins will be stored in a locked kitchen cabinet under the sink. A fire extinguisher is located inside the dining room which was observed to be charged and serviced as of July 1, 2024. LPA tested the wired smoke detectors/carbon monoxide detectors which tested operational. LPA observed a fire place in the living room which was observed to not be in operation at the time of visit. LPA observed that the centrally stored medication will be kept in a locked kitchen cabinet. LPA observed a First Aid kit in the dining room which had all the required components. LPA observed chemicals and toxins to be stored in a locked cabinet in the laundry room. The door leading to the attached two car garage can be locked and will be inaccessible to clients in care. LPA observed the two car garage to be used for storage.

LPA and the AD toured the exterior of the facility and observed it to be free of obstructions and hazards. LPAs observed a shaded outdoor seating area with furniture for client use. The perimeter gates on the north side and southside of the facility are self-latching and can be opened in an evacuation. LPA observed a pool located in the backyard. LPA observed the pool to be adequately fenced and kept locked for client safety.

Component III was completed with the AD which provided information about how to operate the facility within compliance and reporting requirements. The AD was notified that the final application approval will be issued by the Centralized Applications Bureau (CAB) in Sacramento. An exit interview was conducted with Administrator Miriam Salcedo and a copy of the report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
LIC809 (FAS) - (06/04)
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