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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005803
Report Date: 12/23/2024
Date Signed: 12/23/2024 11:19:51 AM

Document Has Been Signed on 12/23/2024 11:19 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:A TOUCH OF SERENITY RESIDENTIAL CAREFACILITY NUMBER:
306005803
ADMINISTRATOR/
DIRECTOR:		JUAN REYESFACILITY TYPE:
740
ADDRESS:24562 ARTEMIA AVETELEPHONE:
(949) 633-5336
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 5DATE:
12/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:Juan Reyes, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Staff #1 at 8:20 am. During today’s visit, LPA met with Juan Reyes, Administrator (AD).

The facility is a single-story building with an approved fire clearance of six non-ambulatory residents of which four may be on hospice. The five bedroom, two bathroom and two car garage facility currently has a census of five residents in care with one resident on hospice.

During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in two of two resident bathrooms, and testing auditory devices on all exits.. The hot water temperature measured between 114.6 and 117.9 degrees Fahrenheit and all smoke and carbon monoxide detectors were operational. The fire extinguisher is charged and was serviced on December 12, 2024. The facility’s last fire drill was conducted on December 5, 2024. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. All appliances were operational and knives and toxic chemicals were secured. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. The First Aid kit had all the required elements and included a First Aid book.

LPA reviewed three of three staff training and fingerprint records and conducted a complete review of resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a pending renewal administrator certificate which expired on December 2, 2024. AD had proof of submitting renewal documents in September and the check was cashed.
(Continued on LIC 809-C)
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2024
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: A TOUCH OF SERENITY RESIDENTIAL CARE
FACILITY NUMBER: 306005803
VISIT DATE: 12/23/2024
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(Continued from LIC 809)

LPA observed residents watching a movie in the living room. Home health was attending to one resident and two were relaxing in their beds. There is a covered outdoor seating area next to a pool that has the required fencing that is locked and secured. All exterior gates were self-latching and there were no hazards obstructing the exit pathways. All exit doors had working auditory devices.

Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Juan Reyes, Administrator and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC809 (FAS) - (06/04)
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