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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004034
Report Date: 03/04/2025
Date Signed: 03/04/2025 11:05:03 AM

Document Has Been Signed on 03/04/2025 11:05 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SERENE VALLEY CARE HOMEFACILITY NUMBER:
306004034
ADMINISTRATOR/
DIRECTOR:		SCOTT, JAMESFACILITY TYPE:
740
ADDRESS:24321 BLUERIDGE ROADTELEPHONE:
(949) 951-1948
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 6DATE:
03/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Caregiver Prescilla MarianoTIME VISIT/
INSPECTION COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by care giving staff after explaining the purpose for the visit. Administrator (AD) James Scott was notified via telephone but could not arrive to assist with the inspection. LPA observed that Administrator James Scott has a valid Administrator certificate which expires on February 26, 2027.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents with a hospice waiver for six. The facility is a single-story home with four resident bedrooms, two of which are shared, one staff bedroom, three shared resident bathrooms, a living room, a family room, a dining room, a kitchen, a laundry room, and an attached two car garage. LPA accompanied by a care giving staff conducted a tour of the interior portion of the facility. On today's visit, LPA observed six residents in care, four of which are on hospice, and two care giving staff present. LPA observed residents relaxing in the living room as well as their respective bedrooms. LPA observed the See Something, Say Something poster (PUB 475) mounted on a wall in the living room. LPA inspected the four resident bedrooms, and they were observed to be free of any hazards. LPA observed the resident bedrooms had the required furnishings of a bed, a chair, a chest of drawers, and a lamp. All resident beds had clean linens and blankets. LPA observed additional linens are stored in hallway closets. LPA inspected the three shared resident bathrooms. Resident bathrooms are clean. Bathrooms are equipped with grab bars and non-skid floor mats. Faucets and toilets were operational. Hot water temperature measured between 108.6 and 110.1 degrees Fahrenheit. LPA observed the staff room is kept locked and inaccessible to residents in care.

LPA observed the kitchen has a two day perishable and seven day nonperishable food supply on hand. LPA observed kitchen appliances to be clean and operational. The five top electric stove was operational. LPA observed kitchen knives are stored in a locked kitchen cabinet. LPA observed toxins and chemicals to be stored in a locked kitchen cabinet under the sink. CONTINUED ON LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2025
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SERENE VALLEY CARE HOME
FACILITY NUMBER: 306004034
VISIT DATE: 03/04/2025
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Fire extinguishers are located in the resident hallway, in the kitchen, and in the two car garage. Fire extinguishers were observed to be charged and up to date on service. LPA tested the wired smoke detectors which tested operational. LPA tested the carbon monoxide detectors which tested operational. LPA observed the facility conducted their last emergency disaster drill on January 18, 2025. The centrally stored medication is kept in a locked storage cabinet in the family room. A First Aid kit was observed be stored in the family room and it had all the required components. LPA observed an internet device for dedicated resident use in the family room. LPA observed chemicals and toxins to be stored in a locked cabinet in the laundry room. The door leading to the attached two car garage is kept locked and inaccessible to resident. The garage is used for storage. LPA observed the facility has a three day emergency food and water supply stored in the garage.

LPA and a care giving staff conducted a tour of the exterior portion of the facility. LPA observed the exterior portion to be clear of obstructions and hazards. LPA observed a shaded outdoor seating area with furniture for resident use. The perimeter gates on the north side and southside of the facility are self-latching and can be opened in an evacuation. There are no bodies of water on the premises.

LPA reviewed all six resident files. All the required documentation were present and current in the resident files reviewed. LPA reviewed six residents’ medication and medication records. LPA reviewed two staff files. All staff are background cleared and associated to the facility.

Based on today's observations, there are no deficiencies being cited per Title 22 of the California Code of Regulations. An exit interview was conducted with an authorized facility representative and a copy of the report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC809 (FAS) - (06/04)
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