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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530148
Report Date: 08/22/2023
Date Signed: 08/22/2023 11:08:12 AM

Document Has Been Signed on 08/22/2023 11:08 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, INC.FACILITY NUMBER:
365530148
ADMINISTRATOR:LEWIS, HAZELFACILITY TYPE:
735
ADDRESS:13400 DOVER LANETELEPHONE:
(760) 596-4385
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 4CENSUS: 0DATE:
08/22/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Hazel Lewis-AdministratorTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Michelle Echeverria , arrived at Serenity Adult Care Homes Inc, to conduct an announced Pre-Licensing visit for a change of location. LPA was greeted by Licensee Darleene Simpson and Administrator Hazel Lewis. LPA introduced self and stated purpose of the visit. LPA toured the facility inside and outside and observed the following:

Structure: Facility is a one story house with four client bedrooms, three bathrooms, living room, dining area, kitchen, pantry, laundry room and an attached two car garage.

Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the hallway to control entire house.

Bedrooms: Each client bedroom will accommodate ambulatory only clients. This is a change in location and all client bedroom furniture will be moved with the clients.

Bathrooms: The client/staff bathrooms have a working toilet, wash basin, and shower with an adequate supply of toilet paper and soap.

Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives, sharps, detergent and chemicals will be stored in a locked hallway closet. There was a pantry stocked with non-perishable food. LPA observed the stove to be operational. Refrigerator/freezer were in working condition. Water tested in the kitchen faucet measured at 112.5 degrees fahrenheit. Laundry room where washer and dryer will be placed is in the hallway leading to the garage.

Living/Family room: There was a living/family room with enclosed fireplace, board games and tv observed. Furniture will be moved from other facility to this facility.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2023
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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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, INC.
FACILITY NUMBER: 365530148
VISIT DATE: 08/22/2023
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Linens and Hygiene Supplies: An adequate supply of linens will be stored in a cabinet in the hallway of the residence. Hygiene supplies will be stored in the hallway closet.

Yards/Outside: Patio furniture for outdoor will be relocated from previous location. Self-latching handle fencing on left side of the house that leads into the backyard. There is no swimming pool or bodies of water observed. All outdoor pathways were free of obstructions.

Emergency Phone Numbers, and Exit Plan: Facility sketch, CCL complaint poster, house rules, personal rights and Emergency and Disaster Plan were observed posted in the living room.

General items: The smoke and carbon monoxide detectors were tested and are operable. There was a fully charged fire extinguisher observed. Client/Staff records will be stored in a locked cabinet located inside the garage. First Aid kit with required components, and locked area for medication storage was observed. LPA observed a facility phone and was operational as evidenced by LPA dialing the number. The phone number designated for the facility is 760-596-4385.

The facility was evaluated in accordance with the CCR, Title 22 California Code of Regulations. Based on the observations and evaluation of the facility this date, the facility’s ready for licensure. Component III was completed on this day as well.

An exit interview was conducted, and a copy of this report LIC809 and LIC809C was discussed and provided with Administrator, Hazel Lewis.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
LIC809 (FAS) - (06/04)
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