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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800059
Report Date: 12/27/2023
Date Signed: 12/27/2023 02:52:16 PM

Document Has Been Signed on 12/27/2023 02:52 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
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:
12/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:43 PM
MET WITH:Darleene Simpson Boyce-AdministratorTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Michelle Echeverria conducted an unannounced visit to the facility to conduct a case management visit and follow up on an adult client death. LPA met with Administrator, Darleene Simpson Boyce who was informed of the purpose of the visit.

This case management visit consisted of collecting pertinent documentation and conducting staff interview regarding the death of Client #1(C1).

Boyce stated that C1's sibling informed her that an autopsy is pending and could take up to 12 weeks, yet the emergency room reported that the cause of death was due to serotonin syndrome. At the moment there is no official death certificate. Boyce also stated that C1 had a pulse when the paramedics took C1 to the emergency room. LPA has advised the administrator to send a copy of the death certificate to Community Care Licensing (CCL) Riverside Regional Office as soon as it is available.

LPA toured the facility inside and out and there was no imminent health and/or safety concerns observed at the time of visit.

An exit interview was conducted where this report was discussed with Administrator, Darleene Simpson Boyce and a copy was provided at the conclusion of the visit.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2023
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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