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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426546
Report Date: 06/19/2024
Date Signed: 06/19/2024 03:54:56 PM


Document Has Been Signed on 06/19/2024 03:54 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 ASSISTED LIVINGFACILITY NUMBER:
336426546
ADMINISTRATOR:VIEYRA AVILES, YENNYFACILITY TYPE:
740
ADDRESS:3879 LAFAYETTE STTELEPHONE:
(951) 977-9137
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY:6CENSUS: 3DATE:
06/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Yenny Aviles - AdministratorTIME COMPLETED:
04:05 PM
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with Administrator, Yenny Aviles, who was informed of the purpose of the visit. At the time of the visit there was two (2) staff and three (3) clients present. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:

Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for clients. Detergents, cleaning solutions, and sharp and dangerous objects were observed to be locked and inaccessible. The smoke detector and carbon monoxide was operational, and the hot water temperature met department requirements. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.



LPA reviewed two (2) staff files and training. All staff have the required personnel records on file and criminal record clearance and updated training along with CPR/First Aid. Two (2) resident files were reviewed and possessed all required paperwork which included Admissions Agreement and Physician's Report. The listed administrator possesses a current administrator's certificate. Resident medication was centrally stored and locked in a cabinet located in the staff office. LPA reviewed medications prescribed to the residents and found all medication with required labeling found to be in place. LPA reviewed the facility's emergency and disaster plan and infection control plan. All facility exits were clear from obstructions. LPA observed emergency supplies and first aid kit with all required items. Fire extinguishers were fully charged and inspected. No deficiencies were cited at the time of the visit.

An exit interview was conducted where a copy of this report was provided to Administrator Vieyra.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024
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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