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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881353
Report Date: 03/28/2024
Date Signed: 03/28/2024 09:56:18 AM

Document Has Been Signed on 03/28/2024 09:56 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
RIVERSIDE ASC, 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) 927-5899
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY: 3CENSUS: 0DATE:
03/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Charlees Tippens, AdministratorTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA), Stephanie Martinez, made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was greeted and allowed to enter the facility to conduct the inspection. On today’s visit the LPA met with Administrator, Charlees Tippens; she was notified of the purpose for the visit. Currently there are no clients in the home.

PHYSICAL PLANT: Outdoor and indoor passageways are kept free of obstruction. No pool or body of water was observed on the property. According to the Administrator, there are no weapons kept in the home. A comfortable temperature was being maintained in the home. There was sufficient lighting in all rooms to ensure the comfort and safety of clients. Toilets, hand washing and bathing facilities were kept safe, sanitary, and in operating condition. Additional equipment for physically handicapped clients is available.

Supplies: The home has sufficient supplies for client needs. A First Aid kit was available and observed to be complete.

RECORD REVIEW: Administrator Tippens has an active Administrator's certificate, which expires on 09/24/2024. The facility's Plan of Operation and Emergency Plan were observed to be available at the facility. The facility's Liability Insurance is active and current; it expires on 03/07/2025.

No deficiencies were cited at time of inspection. This report was reviewed with Administrator Tippens and a copy was provided.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2024
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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