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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880923
Report Date: 12/13/2023
Date Signed: 12/13/2023 10:40:29 AM

Document Has Been Signed on 12/13/2023 10:40 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, IIIFACILITY NUMBER:
361880923
ADMINISTRATOR:SIMPSON, DARLEENEFACILITY TYPE:
735
ADDRESS:14995 HUNTINGTON STTELEPHONE:
(714) 225-2482
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY: 4CENSUS: 4DATE:
12/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Aymboree Santos, Direct Support ProviderTIME COMPLETED:
10:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced case management visit to the facility. LPA met with Aymboree Santos, Direct Support Provider and discussed the purpose of the visit.

During the visit, LPA Malcore requested client records for review, however client files are kept locked and staff present did not have access to the locked files. LPA Malcore called Administator, Darlene Simpson, and left a voicemail message. LPA will return at a later time to obtain pertinent documentation.

Based on LPA observations, a deficiency is being cited per Title 22, Division 6 of The California Code of Regulations.

An exit interview was conducted and copies of the licensing reports with appeal rights were provided to direct support staff, Santos at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2023
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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Document Has Been Signed on 12/13/2023 10:40 AM - It Cannot Be Edited


Created By: Magda Malcore On 12/13/2023 at 10:14 AM
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, III
FACILITY NUMBER: 361880923

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/18/2023
Section Cited
CCR
80066(c)

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All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. This requirement is not met by:
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Licensee/Administrator shall submit to the licensing agency a statement of understanding that records shall be readily available for licensing agency review.
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Licensee did not comply with the section cited by staff present at the did not have access to locked client files.
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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.
SUPERVISOR'S NAME:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023


LIC809 (FAS) - (06/04)
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