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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880650
Report Date: 12/16/2024
Date Signed: 12/16/2024 12:15:25 PM

Document Has Been Signed on 12/16/2024 12:15 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SERENE VALLEY HOMESFACILITY NUMBER:
361880650
ADMINISTRATOR/
DIRECTOR:		LOPEZ, GARYFACILITY TYPE:
735
ADDRESS:15595 BOW STRING STTELEPHONE:
(760) 243-4765
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY: 4CENSUS: 3DATE:
12/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Administrator, Gary LopezTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On 12/16/2024 at 9:35 AM, Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection. LPA was greeted by Administrator Gary Lopez and gained access to the home. Licensee/Administrator Gary Lopez was informed of the purpose of the visit.

The facility has seven (7) bedrooms, four (4) bathrooms, kitchen, dining room, living room, attached three (3) car garage, and backyard. The facility is vendorized by Inland Regional Center (IRC). LPA completed a walk through of the facility, review of records, and medications audit.



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPA confirmed that three (3) clients were at the day program. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 69 degrees Fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs, and sufficient lighting. LPA inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 115-120 degrees Fahrenheit. The facility is equipped with operational smoke detectors and carbon monoxide detectors, two charged fire extinguishers, and first aid kit with first aid book.

Posters such as; the personal rights, CCLD complaint poster, labor laws, and emergency disaster plan were posted in a common area. Client medications were kept in a secure locked office on the second (2) level of the residence and inaccessible to clients. LPA Small observed night lights in he hallways leading to clients' shared bathroom and in client bedrooms. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.
*** Continuation in LIC809C ***
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SERENE VALLEY HOMES
FACILITY NUMBER: 361880650
VISIT DATE: 12/16/2024
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Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the right side of the house that leads into the backyard, attached three (3) car garage observed. All outdoor pathways were free of obstructions.

Food Service: LPA observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.


Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA reviewed three (3) client files for admission agreements, medical assessments/physician reports and Individual Program Plan (IPP). LPA Small observed files to be complete. LPA also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPA obeserved the First Aid/CPR certification for Administrator Gary Lopez to be expired, a Technical Assistance was given. LPA observed staff files to be complete.

LPA Small audited three (3) clients’ medications and no issues were observed. LPA audited three (3) client's Personal and Incidental (P&I) and no issues were observed.

A Technical Assistance was provided during this visit. An exit interview was conducted where this report LIC809, LIC809C and LIC9102 were discussed, and copies were provided to Licensee/Administrator Gary Lopez.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
LIC809 (FAS) - (06/04)
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