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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881353
Report Date: 02/19/2026
Date Signed: 02/19/2026 12:48:19 PM

Document Has Been Signed on 02/19/2026 12:48 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SERENITY HOME LIVINGFACILITY NUMBER:
331881353
ADMINISTRATOR/
DIRECTOR:		TIPPENS, CHARLEES SFACILITY TYPE:
735
ADDRESS:25383 ROCKFORD STREETTELEPHONE:
(951) 927-5899
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY: 3CENSUS: 2DATE:
02/19/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Staff, David WalkerTIME VISIT/
INSPECTION COMPLETED:
12:56 PM
NARRATIVE
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On February 19, 2026, Licensing Program Analyst (LPA), Jarred Torres, and LPA, Armando Perez, arrived at the facility unannounced to conduct an inspection and met with Admin Charlees Tippins. A facility file review was conducted at the regional office and additional records were requested and reviewed at the facility. The facility is licensed for 3 adults and is currently operating at a capacity of two adults.

LPA Torres and LPA Perez toured the facility along with administrator Tippens and made observations pertaining to the annual visit. The LPAs inspected the facility inside and outside. There were no obstructions or debris to the indoor nor outdoor passageways at the time of this visit. Additionally, there were no bodies of water on the premises. The facility is a single-story home located at 25383 Rockford Street, Hemet, CA 92544.

The LPAs were given a tour of the physical plant. The facility phone number is 951-927-5899 and is operable. The LPAs observed the residents' bedrooms which were equipped with the required furniture as stated in Tittle 22 of the California Code of Regulations (CCR). The LPAs observed the bathrooms to be clean and free of dust and debris. The facility's appliances were observed to be operational at the time of this visit. The facility is equipped with operational smoke detectors and a carbon monoxide detector. The LPAs observed fire extinguishers in good condition which had been serviced on 8/22/2025. The LPAs observed the required postings regarding safety, personal rights, and emergency exits. The cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. There was a designated storage space for the resident and staff files. The furniture in the facility is in good condition. The facility's cooling and heating system is operational and the LPAs observed the air temperature at 79 degrees Fahrenheit and the hot water at 110 degrees Fahrenheit.
NAME OF LICENSING PROGRAM MANAGER: Jazmond D Harris
NAME OF LICENSING PROGRAM ANALYST: Jarred Torres
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 02/19/2026 12:48 PM - It Cannot Be Edited


Created By: Jarred Torres On 02/19/2026 at 11:50 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SERENITY HOME LIVING
FACILITY NUMBER: 331881353

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.2(b)(1)(C)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, record review, and observations, the licensee did not comply with the section cited above in 1 of 2 clients' files, there was a missing medical assessment which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2026
Plan of Correction
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Licensee stated they will e-mail the completed physician's report by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jazmond D Harris
NAME OF LICENSING PROGRAM MANAGER:
Jarred Torres
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2026


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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SERENITY HOME LIVING
FACILITY NUMBER: 331881353
VISIT DATE: 02/19/2026
NARRATIVE
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The LPAs observed the medications to be locked and inaccessible to residents in care. The medication supply was sufficient for the two residents in care. No discrepancies with medication were observed.

The LPAs observed an adequate food supply of non-perishable and perishable foods which consisted of frozen meats, vegetables, drinks, and fruits. The dishes and utensils were in sufficient supply.

The LPAs observed adequate staff being present for the supervision of the residents in care. Floor plans, telephone numbers and personal rights were found posted in the facility. The licensee, Charlees Tippens, has a valid Adult Residential Facility license which expires on 9/24/2026.

The LPAs reviewed staff files and client files. The staff files are current, which includes, but is not limited to, TB tests showing a negative result, completed trainings, first aid certifications, and CPI certifications. Resident files were reviewed and the LPAs observed one out of two client files being incomplete by not having a medical assessment in the file. The LPAs discussed with the licensee, and a deficiency will be issued and a plan of correction was agreed upon. The licensee will obtain an updated medical assessment and e-mail it to CCLD within two weeks to make the client file complete.

The LPAs reviewed the emergency disaster plan and fire clearance. The last emergency disaster drill was conducted on 2/1/2026. The emergency disaster plan meets the department's standards.

The LPAs observed the hand washing stations in the facility restrooms. The restrooms contained the required non-medicated soaps and single-use hand towels. Additionally, the facility has an approved infection control plan in their files.

The LPAs issued a Technical Assistance regarding safeguarding of cash for clients in care. The facility did not have the key on site and had to be delivered by Licensee. The LPAs discussed alternative solutions to ensure cash is accessible to clients in a reasonable time frame to meet regulation requirements.

An exit interview was conducted and plans of corrections were reviewed and developed with the licensee. A copy of this report, LIC 809-D, and Appeal Rights were discussed and provided to the licensee, whose signature on this form confirms receipt of these documents. Please refer to LIC 809-D.
NAME OF LICENSING PROGRAM MANAGER: Jazmond D Harris
NAME OF LICENSING PROGRAM ANALYST: Jarred Torres
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2026
LIC809 (FAS) - (06/04)
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