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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602937
Report Date: 12/07/2022
Date Signed: 12/07/2022 01:48:06 PM


Document Has Been Signed on 12/07/2022 01:48 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
RIVERSIDE, CA 92507



FACILITY NAME:APK SERENE, HANNALEIFACILITY NUMBER:
374602937
ADMINISTRATOR:JOSEPH LUEVANOFACILITY TYPE:
735
ADDRESS:1645 SOUTH HANNALEI DRTELEPHONE:
(714) 488-6495
CITY:VISTASTATE: CAZIP CODE:
92083
CAPACITY:4CENSUS: 3DATE:
12/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:LEAD FACILITY CAREGIVER, KESORN DEBOW.TIME COMPLETED:
01:55 PM
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On December 07, 2022, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility for an unannounced required annual with emphasis on infection control. LPA Mixson was greeted and granted entry by Facility Staff, Carmen Hernanandez introduced self and stated the purpose of the visit.

Present in the facility are 3 residents and 2 caregivers. There are currently no cases of COVID-19 within the facility. All staff and all residents have been vaccinated, and boosted.

LPA Mixson met with Lead Facility Caregiver, Debow and toured the facility. LPA Mixson made observations pertaining to the facility's infection control measures. LPA Mixson observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and the proper use of face coverings.

The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, and cleaning and disinfection provisions are in adequate quantities.

LPA Mixson later discussed infection control practices and procedures with Facility Lead Caregiver.

An exit interview was conducted and a copy of this report, along with the LIC 811 was provided to the Facility Lead Caregiver.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2022
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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