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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530010
Report Date: 08/04/2022
Date Signed: 08/04/2022 01:43:30 PM

Document Has Been Signed on 08/04/2022 01:43 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:SAN BERNARDINO SERENITY LIVINGFACILITY NUMBER:
365530010
ADMINISTRATOR:MAGTOTO, EDWARDFACILITY TYPE:
735
ADDRESS:2414 OGDEN ST.TELEPHONE:
(213) 618-0938
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92407
CAPACITY: 20CENSUS: 15DATE:
08/04/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Edward Magtoto, LicenseeTIME COMPLETED:
01:55 PM
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Licensing Program Analyst (LPA) Rayshaun Nickolas made an announced visit to the facility to conduct a pre-licensing inspection for an initial application. LPA Nickolas identified herself to Licensee, Edward Magtoto, and explained the purpose of the visit.

The pending application is for an Adult Residential Facility (ARF). The facility has been granted a fire clearance for a total capacity of 20 ambulatory clients by the San Bernardino County Fire Protection District on 06/22/2022. The facility has a total of ten resident bedrooms, four resident bathrooms, one staff bedroom, one staff bathroom, a visitor restroom, a kitchen/dining area, a living room, an activity area, an office area, and backyard. LPA toured the interior and exterior areas of the facility. The following was inspected:

LPA inspected bedrooms; the bedrooms have the required bedding and furniture, such as, clean mattresses/linen, sufficient storage space, chairs, and lighting. LPA inspected bathrooms; the bathroom appliances were operating in safe and sanitary conditions and contained appropriate hygiene items for clients. LPA inspected the kitchen; knives, cleaning supplies, and toxins were inaccessible to residents and stored away from food supply. Dishes, glasses, and utensils were in good condition and stored in a safe manner. The kitchen countertop, floors, and appliances were free from debris. There was also a meal menu available for review. LPA inspected the common areas; LPA observed a charged fire extinguisher, operating smoke detectors, and carbon monoxide alarms at the time of visit. LPA observed required postings including visitation policies, personal rights, and the facility's emergency/disaster plan. The facility was equipped with a complete first aid kit. There was a locked and centralized storage area for medications and area for client files and staff files. The facility had a working telephone for client use. There was adequate seating in the common areas. LPA inspected the outdoor space.

The Component III Orientation was completed during the pre-licensing inspection.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: SAN BERNARDINO SERENITY LIVING
FACILITY NUMBER: 365530010
VISIT DATE: 08/04/2022
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The pre-licensing inspection is complete, and this facility has no deficiencies. Licensee has satisfied all requirements in accordance with Title 22, California Code of Regulations (CCR).

An exit interview was conducted where this report was discussed, and a copy was provided to Magtoto at the conclusion of the inspection
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
LIC809 (FAS) - (06/04)
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