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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800059
Report Date: 03/28/2023
Date Signed: 03/28/2023 11:57:33 AM

Document Has Been Signed on 03/28/2023 11:57 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SERENITY ADULT CARE HOMES IIFACILITY NUMBER:
361800059
ADMINISTRATOR:BOYCE, DARLEENEFACILITY TYPE:
735
ADDRESS:14534 HANDSDALE STREETTELEPHONE:
(714) 225-2482
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY: 6CENSUS: 3DATE:
03/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Shameika Leachman-DSPTIME COMPLETED:
12:05 PM
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On 03/28/23 at 09:10 AM, Licensing Program Analysts (LPA's) Michelle Echeverria and Anna Bueno arrived at the facility unannounced to conduct a required Annual visit. LPA's were greeted by DSP, Shameika Leachman. LPA's observed that there is currently 2 clients and an additional DSP present in the home.
LPA's toured the facility inside and outside with Leachman.

The facility has 4 bedrooms, 2 bathrooms, a kitchen, dining area, living room, attached garage, and backyard. LPA's conducted a general overall inspection, which included, but was not limited to, the following:
Physical Plant: There are no obstructions to indoor and outdoor passageways. The facility is maintained at a 74 degrees F temperature. LPA's inspected clients bedrooms; they are equipped with required furniture per regulations. An adequate supply of linens stored in a cabinet in the main hallway of the residence. LPA's inspected client bathroom; bathroom was clean and appliances were operating appropriately. LPA's tested the water temperature in the kitchen faucet, which tested within regulation at 106 degrees F. The facility is equipped with operating fire extinguisher, smoke detectors and carbon monoxide alarms. Posters such as; the personal rights, the CCL complaint poster, and disaster plans were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked. There was a designated locked storage space for client/staff files, first aid kit and medication. The facility had emergency supplies for future clients. There are no pools, bodies of water, firearms or ammunition. Overall, the facility is clean, in good repair, and operating in safe conditions for future clients in care.
Yards/Outside:
One shaded patio, a side gate with self-latching handle on the left side of the house that leads into the backyard. All outdoor pathways were free of obstructions.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SERENITY ADULT CARE HOMES II
FACILITY NUMBER: 361800059
VISIT DATE: 03/28/2023
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Food Service: LPA's observed 2 days of perishables and 7 days non-perishables food, pantry fully stocked and up to date. Facility has a variety of food available. Menu plan along with Special Diet Plan is posted on the kitchen's refrigerator. Dishes, cups, and utensils were stored properly. Emergency food and water were observed inside the garage.
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Record Review: LPA's reviewed the clients files along with the staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings.

No deficiencies were cited during this visit. An exit interview was conducted where this report LIC809 and LIC809-C was discussed and copies were provided to Leachman.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023
LIC809 (FAS) - (06/04)
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