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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881389
Report Date: 01/13/2023
Date Signed: 01/13/2023 11:01:13 AM

Document Has Been Signed on 01/13/2023 11:01 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SERENITY HOUSE OF ESSENCEFACILITY NUMBER:
331881389
ADMINISTRATOR:CARRAWAY, LAQUITAFACILITY TYPE:
735
ADDRESS:1294 PERIWINKLE PLACETELEPHONE:
(714) 833-0484
CITY:SAN JACINTOSTATE: CAZIP CODE:
92582
CAPACITY: 4CENSUS: 0DATE:
01/13/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:ADMINISTRATOR, LAQUITA CARRAWAY.TIME COMPLETED:
11:06 AM
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On January 13, 2023, Licensing Program Analyst (LPA), Venus Mixson conducted a scheduled visit to complete a Pre-licensing inspection. LPA Mixson met with Administrator, Laquita Carraway introduced self and toured the facility inside and out. LPA Mixson observed a single story home with front room, kitchen and dinning area, four bedrooms, two bathrooms, and a two car garage. LPA Mixson observed sufficient food supply, and the overall facility to be in clean condition with a comfortable temperature. LPA Mixson observed passageways to be free from obstruction. Water temperature was tested and found to be within regulation limitations. LPA Mixson observed location where medications will be kept locked and inaccessible. LPA Mixson observed smoke/carbon monoxide detectors in working condition, fire extinguisher charged and in the green. On 11/18/2022, The Riverside County Fire Department cleared the facility for 0 ambulatory, 4 non-ambulatory, and 0 bedridden. LPA Mixson observed first aid kit and manual. The facility is equipped with lights in the passages, a screened cover on the fireplace, and plenty of natural light. The facility is also stocked with emergency night lights throughout. LPA Mixson observed the sharp objects are locked in a kitchen drawer. All doors, and passageways are clear from obstruction. All beds have the required linen and supplies. There was enough clean linen and hygiene items. There was appropriate lighting in each room with night stand and chair. LPA Mixson observed central heating and air conditioning systems. The Administrator dialed the land line phone number (951) 665-3151 it was operable. Outside/Yards: No obstructions observed. An exit interview conducted copy of this report was provided to Administrator. COMP III reviewed.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2023
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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