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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881389
Report Date: 01/06/2025
Date Signed: 01/06/2025 02:10:56 PM

Document Has Been Signed on 01/06/2025 02:10 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 HOUSE OF ESSENCEFACILITY NUMBER:
331881389
ADMINISTRATOR/
DIRECTOR:		CARRAWAY, LAQUITAFACILITY TYPE:
735
ADDRESS:1294 PERIWINKLE PLACETELEPHONE:
(714) 833-0484
CITY:SAN JACINTOSTATE: CAZIP CODE:
92582
CAPACITY: 4CENSUS: 3DATE:
01/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:48 AM
MET WITH:ADMINISTRATOR, LA QUITA CARRAWAYTIME VISIT/
INSPECTION COMPLETED:
02:18 PM
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On January 06, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the Required Annual Inspection and met with the Administrator, La Quita Carraway. The facility is licensed for four Adults and is currently operating at a capacity of three Adults.

LPA Mixson toured the facility along with the Administrator, La Quita Carraway and made observations pertaining to the annual visit. LPA inspected the facility inside and outside there were no obstructions or debris to the indoor or 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 1294 Periwinkle Place San Jacinto, CA. 92582.

Physical Plant: The facility phone number is (951) 665-3151 and it is operable. LPA Mixson observed the residents’ bedrooms, and each was equipped with required furniture as per Title 22. LPA Mixson inspected facility bathrooms, and the hot water temperature tested within regulations. The bathrooms were clean, and appliances were operating appropriately. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and a fire extinguisher. Fire extinguisher was service in December 2024, by Elite Fire Protection. LPA Mixson observed required postings such as "If you See Something, Say Something,” the "Personal Rights." The cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. There was a designated storage space for the residents and staff files, and it was locked and inaccessible to residents in care currently.

Medications: Were locked and inaccessible to residents in care, and there was a sufficient supply of medication for each resident. The overall facility is clean, the furniture is in good condition. The facility heating and cooling system and other appliances were operable currently at the time of this visit. Administrator informed LPA there were safety lights for night throughout the facility.

Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly, and sharp items are locked.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2025
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SERENITY HOUSE OF ESSENCE
FACILITY NUMBER: 331881389
VISIT DATE: 01/06/2025
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Care & Supervision/Administration: Adequate staff are present for the supervision of resident in care. Floor plans, telephone numbers and personal rights were found posted in the facility. The listed administrator possesses a current administrator’s certificate with an expiration date of 08/06/2026.

Records Reviewed and Resident/Staff Files: LPA reviewed staff files and reviewed the facility's staff schedule. The staff files reviewed have criminal clearance and updated training along with First Aid Certification. Resident files were reviewed and possessed all required paperwork, including up to date TB test.



Disaster preparedness: LPA Mixson reviewed the facility's emergency and disaster plan and required documents were observed at this time. A disaster training binder was reviewed and it maintained the required information as requested per regulations. LPA observed the last disaster drills and each met the department standards.

Infection Control: LPA Mixson observed the hand washing stations in the facility restrooms. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan and found the required infection control measures as required.



There were no TA deficiencies observed or cited per Title 22, Division 6 of the California Code of Regulations at this time.

An exit interview was conducted where a copy of this report was discussed and given to Administrator, La Quita Carraway.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025
LIC809 (FAS) - (06/04)
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