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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880650
Report Date: 10/27/2022
Date Signed: 10/27/2022 11:59:57 AM

Document Has Been Signed on 10/27/2022 11:59 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:SERENE VALLEY HOMESFACILITY NUMBER:
361880650
ADMINISTRATOR:LOPEZ, GARYFACILITY TYPE:
735
ADDRESS:15595 BOW STRING STTELEPHONE:
(760) 243-4765
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY: 4CENSUS: 3DATE:
10/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:12 AM
MET WITH:Jacob Lopez, DSPTIME COMPLETED:
12:02 PM
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to conduct a required annual inspection with an emphasis on infection control. LPA identified herself to DSP Jacob Lopez, who was also informed of the purpose of the visit.

During the inspection, LPA interviewed DSP Lopez regarding the facility's infection control measures and inspected the facility for regulatory compliance. LPA observed appropriate postings in the facility, including COVID-19 symptoms postings and visitation policies, which were in accordance with the Department's guidelines. LPA observed that the facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and a supply of Personal Protective Equipment (PPE). The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation, and properly caring for clients with COVID-19 positive results and/or exposures.

LPA and DSP toured the inside and outside of the facility. LPA and DSP observed an unused and secured body of water. The facility is equipped with sufficient food supply and emergency supplies. The combination smoke alarm and carbon monoxide detectors were functional and the fire extinguisher was last inspected on 7/2/22. LPA observed that all utilities and appliances were functioning properly and all passageways clear of obstruction. All areas of the facility, including client bedrooms and restrooms, appeared clean and in good repair. LPA observed that medications and toxins were kept inaccessible to clients in care. LPA observed no apparent health and safety risks at the time of visit. The facility appeared to be meeting operational requirements.

An exit interview was conducted where a copy of this report was reviewed with and provided to DSP Lopez.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2022
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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