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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005761
Report Date: 08/17/2021
Date Signed: 08/17/2021 10:56:08 AM

Document Has Been Signed on 08/17/2021 10:56 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:TOUCH OF SERENITY SENIOR CAREFACILITY NUMBER:
306005761
ADMINISTRATOR:REYES, NAYEHYFACILITY TYPE:
740
ADDRESS:24511 SATURNA DRIVETELEPHONE:
(949) 633-5336
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 4DATE:
08/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Nayehy ReyesTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted, filled out covid survey, temperature checked upon arrival and granted entry into the facility by Staff and explained the reason for the visit.

During the visit LPA toured the facility with Administrator Nayehy Reyes. Facility is a 6 bedroom,( 5 resident bedrooms 1 staff bedroom) and 4 bathrooms single story home. There are 4 Residents in care. LPA observed proper covid signage at front entrance and throughout facility as well as a sign in, sanitization and temperature check station. Facility has required Department postings. LPA observed copy of Administrators Certificate expiring August 19, 2021. LPA toured all Residents rooms, all rooms where within regulations. All restrooms observed contained soap, toilet paper, paper towels and gloves. Restrooms had proper hand washing signs posted. Residents were observed relaxing in the dining room eating and relaxing in bedrooms. Facility has audible alarms for each sliding door entrance/exit. Facility has 1 fire extinguisher which was fully charged. Facility has ample supply of PPE. Facility has 2 refrigerators with ample food supply. LPA observed facility has emergency food and water supply. Facility has required Emergency Disaster Plan posted on wall. Facility has a secured location for resident medication and files. Facility has 30 days supply of medications for Residents. Residents emergency contact information are current. Facility has several designated visitation areas.

No deficiencies noted during todays visit. An exit interview was conducted with Administrator Reyes and a copy of report was left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2021
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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