<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880923
Report Date: 12/11/2024
Date Signed: 12/11/2024 01:49:34 PM

Document Has Been Signed on 12/11/2024 01:49 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, IIIFACILITY NUMBER:
361880923
ADMINISTRATOR/
DIRECTOR:		SIMPSON, DARLEENEFACILITY TYPE:
735
ADDRESS:14995 HUNTINGTON STTELEPHONE:
(714) 225-2482
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY: 4CENSUS: 3DATE:
12/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Latanya Pearson-Clay- House ManagerTIME VISIT/
INSPECTION COMPLETED:
02:05 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Staff, Aymboree Santos and introduced self and stated purpose of the visit.

The facility has 4 bedrooms, 2 bathrooms, kitchen, dining area, living room, office area, backyard, laundry room, and attached garage. LPA completed a walk through of facility, review of records, medication and P&I audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 75 degrees fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA observed that the client's master bedroom closet is used for the facility's hygiene/toiletry products which invades the client's privacy. Deficiency issued. LPA observed two clients broken bedroom window screens. Deficiency issued. LPA inspected client bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 119.4 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, charged fire extinguisher and first aid kit. Posters such as; the personal rights, state license and CCL complaint poster were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked and inaccessible to clients. There was a designated storage space for client/staff files. Medications was observed locked and inaccessible to clients. There is no swimming pool, bodies of water, firearm or ammunition in the facility. 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. Facility has a wide variety of food available. Dishes, cups, and utensils were also stored properly.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 12/11/2024 01:49 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 12/11/2024 at 01:12 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, III
FACILITY NUMBER: 361880923

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087(a)(4)
Building and Grounds
(4) No client bedroom shall be used as a public or general passageway to another room, bath or toilet.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the administrator did not comply with the section cited above by storing hygiene and toiletry products inside the client's master bedroom closet and invading their privacy which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/13/2024
Plan of Correction
1
2
3
4
Administrator stated that the hygiene products and toiletry will be removed from the client's master bedroom closet and will send a picture as proof to LPA via email by POC due date.
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the administrator did not comply with the section cited above by not replacing the two clients bedroom window screens which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/13/2024
Plan of Correction
1
2
3
4
Administrator stated that she will replace the two clients bedroom window screens and send pictures as 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.
SUPERVISOR'S NAME:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 12/11/2024 01:49 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 12/11/2024 at 01:12 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, III
FACILITY NUMBER: 361880923

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the administrator did not comply with the section cited above by not having staff assist the client with their medication as prescribed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/18/2024
Plan of Correction
1
2
3
4
Administrator stated that she will conduct a refresh training on the regulation cited with staff and send the signed attendance sheet to LPA via email by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
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.
SUPERVISOR'S NAME:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
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, III
FACILITY NUMBER: 361880923
VISIT DATE: 12/11/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Yards/Outside: One shaded patio, and side gate with self-latching handle on the right 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.

Record Review: LPA reviewed administrator and staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA reviewed client file for admission agreements, updated physician reports, and needs and services plans. P & I funds was counted and matched with the ledger. Medication was audited and did not match with MARS. LPA observed that one client's medication was not given as prescribed by doctor's orders. Deficiency issued. LPA reviewed facility's file for emergency drills, liability insurance policy, surety bond and emergency disaster plan. LPA observed that the Emergency Disaster Plan was not reviewed annually. Technical violation issued.

Deficiencies and one technical violation were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102TV and appeal rights were discussed and copies were provided to Latanya Pearson-Clay.

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

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5