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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880775
Report Date: 02/13/2025
Date Signed: 02/13/2025 11:07:43 AM

Document Has Been Signed on 02/13/2025 11:07 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 IVFACILITY NUMBER:
361880775
ADMINISTRATOR/
DIRECTOR:		BOYCE, DARLEENEFACILITY TYPE:
735
ADDRESS:11542 AUTUMN STREETTELEPHONE:
(760) 523-1108
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY: 4CENSUS: 2DATE:
02/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:02 AM
MET WITH:Julia Broadway- House ManagerTIME VISIT/
INSPECTION COMPLETED:
11:22 AM
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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 House Manager, Julia Broadway and granted entrance. LPA introduced self and stated the purpose of the visit. LPA observed that there are currently 2 clients in the facility. LPA began the tour of the facility with Julia.

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 77 degrees Fahrenheit. LPA inspected clients bedrooms; they are equipped with required furniture per regulations. LPA observed broken window blinds in the living room and client's bedrooms. Technical violation issued. An adequate supply of linens stored in the closet. LPA inspected clients bathrooms; bathrooms were clean and appliances were operating appropriately. LPA tested the water temperature which tested at 111.2 degrees Fahrenheit. The facility is equipped with operating fire extinguishers, smoke alarms and carbon monoxide alarms. Last fire drill was conducted on 1/23/25. 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. Facility has a wide variety of food available for clients. Dishes, cups, and utensils were also stored properly. Emergency food, water, and emergency disaster kits were observed inside the facility.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025
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 IV
FACILITY NUMBER: 361880775
VISIT DATE: 02/13/2025
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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: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

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. Medication was audited and matched to MARS. P&I was audited and matched with the ledger. LPA reviewed the Infection Control Plan and observed that it was not reviewed recently. Technical violation issued.

No deficiencies and two technical violations were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, and LIC9102TV were discussed and copies were provided to House Manager, Julia Broadway.

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

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC809 (FAS) - (06/04)
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