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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426546
Report Date: 07/21/2021
Date Signed: 07/21/2021 03:11:55 PM

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 ASSISTED LIVINGFACILITY NUMBER:
336426546
ADMINISTRATOR:VIEYRA AVILES, YENNYFACILITY TYPE:
740
ADDRESS:3879 LAFAYETTE STTELEPHONE:
(909) 653-7912
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY:6CENSUS: 2DATE:
07/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Yenny Vieyra AvilesTIME COMPLETED:
03:21 PM
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Licensing Program Analyst (LPA) Christine Le conducted an unannounced visit to the facility for an annual inspection. LPA initially met with caregiver Alejandra Aviles. The licensee Yenny Vieyra Aviles arrived during the visit.

LPA toured the facility inside and out. The facility has no bodies of water. The facility has charged fire extinguishers, operating smoke alarms, and carbon monoxide detectors. Outdoor and indoor passageways were kept free of obstruction. Cleaning supplies, medications, and sharps were kept in a safe and locked place. Cleaning supplies were stored in the laundry room and garage. Medications were stored in the office. Sharps were stored in a secured area. The facility had a complete first aid kit. LPA observed a two (2) day supply of perishable food items and seven (7) day supply of nonperishable food items. The facility menu was available for review. The resident bedrooms had the required furniture and functional lighting. The facility had a supply of additional linen and extra hygiene items for the residents. LPA toured the resident bathrooms. LPA observed grab bars and non-skid mats. LPA measured the hot water temperature in the bathrooms. The hot water temperature measured at 117 degrees F.

LPA observed that the facility has a mitigation plan to mitigate the spread of COVID-19 in the facility. One central entry point and sign-in policy has been designated for universal entry screening. Routine symptom screening has been initiated at entry for all staff, residents, and visitors. Facility also documents daily temperature and COVID-19 symptom checks, and any change in condition for staff and residents. LPA observed hand sanitizer throughout the facility and a 30 day supply of PPE. All residents have at least a 30 day supply of medications. LPA observed that all emergency contact information for the residents have been updated.

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to the licensee.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Christine LeTELEPHONE: (951) 897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
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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