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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880923
Report Date: 08/11/2022
Date Signed: 08/11/2022 01:24:01 PM

Document Has Been Signed on 08/11/2022 01:24 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, 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: 2DATE:
08/11/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:06 PM
MET WITH:Pebbles Nakielski, AdministratorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Rayshaun Nickolas made an unannounced visit to the facility to conduct a Health and Safety case management visit. This case management visit is in response to an unusual incident/injury report (UIR) that was received by this agency from the facility on June 28, 2022. LPA met with Administrator Pebbles Nakielski and explained the purpose of the visit.

The UIR documents that on June 26, 2022, client # 1 (C1) attempted to absent without leave (AWOL) and staff # 1 told C1 to go back to her room. The UIR documents C1 became increasing aggressive with S1 by snatching a book from S1 hand, hitting and kicking S1, throwing a book out the door, and shoving S1 out the door. The UIR further documents S1 called 911, officers were dispatched to the facility, and C1 was arrested for battery.

LPA reviewed the statements provided by staff regarding the incident, interviewed the administrator, and reviewed C1’s Individual Program Plan (IPP) and Positive Support Plans (PSP). LPAs obtained a copy of the IPP and PSP for C1. .

There are no health and safety concerns observed during this visit. Additional information will be required prior to closure inquiry into this incident.

No deficiencies were cited during this visit. An exit interview was conducted where this report (LIC 809) was discussed and provided to the Administrator.




SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2022
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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