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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880775
Report Date: 01/21/2026
Date Signed: 01/21/2026 02:54:33 PM

Document Has Been Signed on 01/21/2026 02:54 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SERENITY ADULT CARE HOMES IVFACILITY NUMBER:
361880775
ADMINISTRATOR/
DIRECTOR:		BOYCE, DARLEENEFACILITY TYPE:
735
ADDRESS:11542 AUTUMN STREETTELEPHONE:
(760) 523-1108
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY: 4CENSUS: 3DATE:
01/21/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:14 AM
MET WITH:LaTanya Clay- AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced to conduct a required Annual visit. LPA was greeted by Staff, Julia Broadway and granted entrance. LPA introduced self and stated the purpose of the visit. LPA observed that there are currently 3 clients in the facility and 1 staff. Administrator, LaTanya Clay later arrived and LPA informed her about the purpose of the visit.

The facility has 4 bedrooms, 2 bathrooms, kitchen, dining area, living room, office area, laundry closet, garage and backyard. LPA 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 comfortable temperature of 75 degrees Fahrenheit. LPA inspected clients bedrooms; they are equipped with required furniture per regulations. LPA observed that the facility did not have sufficient back up bedding for the clients. Technical violation issued. LPA inspected clients bathrooms; bathrooms were clean and appliances were operating appropriately. LPA tested the water temperature which tested at 116 degrees Fahrenheit. The facility is equipped with operating fire extinguishers, smoke alarms 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 clients/staff files, first aid kit and medication. The facility has a working telephone line. There are no pools, bodies of water, firearms or ammunition. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Dishes, cups, and utensils were also stored properly. Emergency food, water, and emergency disaster kits were observed inside the facility.
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Michelle Echeverria
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 IV
FACILITY NUMBER: 361880775
VISIT DATE: 01/21/2026
NARRATIVE
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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.

Care & Supervision: LPA observed that the 1:1 staff scheduled was not present. Deficiency issued.

Record Review: LPA reviewed client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed that one staff did not have criminal background clearance. Deficiency with civil penalty issued. LPA observed that one staff did not have a transfer request for criminal background clearance. Deficiency issued. LPA observed that one staff did not have a personnel file. Deficiency issued. LPA observed that one staff did not have physical evaluation screening. Deficiency issued. LPA observed one medication missing from the MARS inventory. Technical violation issued. P&I was audited and matched with the ledger. LPA reviewed the facility's infection control plan, emergency disaster plan, liability insurance, surety bond and emergency drills. LPA observed that the infection control plan was last reviewed/updated on 3/12/23. Deficiency issued.

Deficiencies and technical violations were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102TV, LIC421BG and appeal rights were discussed and copies were provided to Administrator, LaTanya Clay.

NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Michelle Echeverria
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 01/21/2026 02:54 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 01/21/2026 at 02:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SERENITY ADULT CARE HOMES IV
FACILITY NUMBER: 361880775

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the administrator did not comply with the section cited above by not having criminal background clearance for one staff working hich poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2026
Plan of Correction
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Administrator stated that the staff will be removed from schedule and proof will be submitted to LPA via email by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Michelle Echeverria
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2026


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 01/21/2026 02:54 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 01/21/2026 at 02:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SERENITY ADULT CARE HOMES IV
FACILITY NUMBER: 361880775

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)(1)(D)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022.  (1) The Infection Control Plan shall include all of the following:  (D) The licensee shall review the use of infection control procedures in the facility at least annually, if local government public health determines an epidemic outbreak has occurred, or if the review is requested by the local licensing agency. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the administrator did not comply with the section cited above by not reviewing/updating the infection control plan since 3/12/23 which poses potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2026
Plan of Correction
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Administrator stated that she will review/update the infection control plan and send proof to LPA via email by POC due date.
Type B
Section Cited
CCR
85065.5(a)(1)
Day Staff-Client Ratio
(1) For Regional Center clients, staffing shall be maintained as specified by the Regional Center but no less than one direct care staff to three such clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the administrator did not comply with the section cited above by not being fully staffed with providing coverage for the 1:1 staff-client which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2026
Plan of Correction
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Administrator stated that she will submit a statement of understanding on the regulation cited to LPA via email by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Michelle Echeverria
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2026


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 01/21/2026 02:54 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 01/21/2026 at 02:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SERENITY ADULT CARE HOMES IV
FACILITY NUMBER: 361880775

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80019(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the administrator did not comply with the section cited above by not having proof of one staff criminal record clearance transfer request which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/28/2026
Plan of Correction
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Administrator stated that she will associate the staff to the facility and provide proof to LPA via email by POC due date.
Type B
Section Cited
CCR
80066(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the administrator did not comply with the section cited above by not having a personnel file for one staff which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/28/2026
Plan of Correction
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Administrator stated that she will create a personnel file for the staff and send proof to LPA via email by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Michelle Echeverria
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2026


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 01/21/2026 02:54 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 01/21/2026 at 02:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SERENITY ADULT CARE HOMES IV
FACILITY NUMBER: 361880775

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
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Based on observation and record review, the administrator did not comply with the section cited above by not having one staff's physical evaluation report which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/28/2026
Plan of Correction
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2
3
4
Administrator stated that she will request the physical evaluation report from the staff and provide proof to LPA via email by POC due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Michelle Echeverria
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2026


LIC809 (FAS) - (06/04)
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