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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881353
Report Date: 01/27/2023
Date Signed: 01/27/2023 01:28:51 PM

Document Has Been Signed on 01/27/2023 01:28 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SERENITY HOME LIVINGFACILITY NUMBER:
331881353
ADMINISTRATOR:TIPPENS, CHARLEES SFACILITY TYPE:
735
ADDRESS:25383 ROCKFORD STREETTELEPHONE:
(951) 927-6899
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY: 3CENSUS: 0DATE:
01/27/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:04 PM
MET WITH:Applicant, Charlees TippensTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Janira Arreola, conducted an announced visit to the facility in order to conduct a prelicensing inspection. LPA met with Applicant, Charlees Tippens, who was informed of the purpose of the visit. The applicant is seeking an initial application for an adult residential home serving population of 18 to 59 years of age.

LPA conducted a walk through of the interior and exterior of the facility. LPA observed the home to be a (3) bedroom (2) bathroom, one story home with attached garage. LPA reviewed the fire clearance for the facility on completed on 9/20/2022 by Riverside County Fire Department granting clearance for (3) ambulatory clients. LPA observed the emergency exits to be free of obstructions. LPA observed the (2) shared resident bedrooms contained the required furniture and linens. LPA observed the resident restroom to have non-slip mat, and required hygiene supplies for future residents. LPA observed the third room which will be used as a staff room with attached bathroom. LPA observed the kitchen to have the required perishable and non-perishable food supplies. The kitchen also possesses enough cooking supplies and utensils for future residents. LPA observed the medication and sharp object storage in the facility dining area, and observed where the cleaning chemicals will be stored locked. LPA observed the laundry equipment to be functional, as well as all other utilities. The hot water temperature was recorded at 106.1F. The facility has a land line at : (951) 927-5899 which was observed to be operational. The back yard was observed to have the required shaded area with enough seating for (3) clients, as well as the facility dining area. LPA reviewed the facility's emergency and disaster plan, and the applicants administrator's certificate. LPA observed all required posting at the facility including those for COVID-19.

NO fire arms or bodies of water are present at the facility. Component III presentation was completed during the time of the visit.

An exit interview was conducted where this report was reviewed and provided to, Applicant, Charlees Tippens.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2023
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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