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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006563
Report Date: 11/01/2024
Date Signed: 11/01/2024 10:04:19 AM

Document Has Been Signed on 11/01/2024 10:04 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 HAVEN ASSISTED LIVING MISSION VIEJOFACILITY NUMBER:
306006563
ADMINISTRATOR/
DIRECTOR:		DAELTO, VEAHLOUFACILITY TYPE:
740
ADDRESS:26751 VIA GRANDETELEPHONE:
(714) 747-4537
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 5DATE:
11/01/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:00 AM
MET WITH:Mary Ann Salvador- Applicant/Administrator
Veahlou Daelto- Administrator		TIME VISIT/
INSPECTION COMPLETED:
10:20 AM
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Licensing Program Analyst (LPA) Jessica Cho arrived announced for the purpose of conducting a Pre-Licensing visit for a Change of Ownership (CHOW). LPA conducted the visit with Applicant/Administrator Mary ann Salvador and Administrator (Admin) Veahlou Daelto. The initial application to operate a Residential Care Facility for the Elderly (RCFE) was received by the Department of Social Services on April 22, 2024 for age ranges 60 and over, for (6) non-ambulatory residents in bedrooms 1-6 of which (1) may be bedridden in bedroom 2 only.

LPA began the tour of the interior and exterior portion of the facility with Caregiver Aira Seleky. Applicant and Administrators arrived approximately 8:00am. The following was observed:

Structure:


The facility is a two story property in a residential neighborhood. The first floor is comprised of six resident bedrooms and two resident full bathrooms. The second level is not accessible to the residents and is used as a living quarter for relatives of the property owner. The first level is comprised of a formal living room, dining area, kitchen, and an attached two car garage which doubles as a laundry room, and there is a private staff room within the garage. The second level has four bedrooms, one full bathroom, kitchen, dining area, and an office. The backyard has one exit gate, and has sufficient shaded seating area. LPA did not observe any obstacles or hazards in the backyard.

Telephone Number:
Facility landline number is (949) 446-6718.

Signal System:
The facility utilizes a signal system where staff is alerted from a central location located from the desk next to Room #6.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2024
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: SERENE HAVEN ASSISTED LIVING MISSION VIEJO
FACILITY NUMBER: 306006563
VISIT DATE: 11/01/2024
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Smoke and Carbon Monoxide Detectors:
The dual functioning smoke detectors/carbon monoxide alert systems and auditory devices were tested and found to be operational.

Fire Extinguishers:
Three fire extinguishers were mounted, fully charged, and serviced on April 5, 2024. .

Fire Clearance:
Approved on May 7, 2024. Please note that bedridden approved in Room 2 only.

Toxins and Sharps:
Cleaning supplies, toxins, and sharps were observed to be secured and inaccessible.

Water Temperature:
The water temperature in the two resident bathrooms measured at 114.0 and 117.3 degrees Fahrenheit.

Medications, First Aid Kit & Manual:
The First Aid Kit was checked and found to be in order. The current first aid manual was ordered during the visit.


Component III:
Component III was completed during today's visit.

The Pre-Licensing is now complete, and the facility is ready for licensure. The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Bureau.

An exit interview was conducted with Applicant/Administrator Mary Ann Salvador and Administrator Veahlou Daelto, and a copy of this report was provided at the end of the visit.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
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 HAVEN ASSISTED LIVING MISSION VIEJO
FACILITY NUMBER: 306006563
VISIT DATE: 11/01/2024
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Bedrooms:
The resident bedrooms had all required components, are spacious, and easily accommodates the residents’ furnishings.

Bathrooms:
Bathrooms were clean and operational. Grab bars were secure and bath slip mats were in place.

Linens and Hygiene Supplies:
Clean linens and hygiene supplies were observed to be fully stocked.

Appliances:
Stove burners, microwaves, refrigerator, freezer, and washer/dryer were inspected and operating.

Resident and Staff Files:
Resident and staff records will be maintained on site.

Reading Material, Games, Equipment, & Materials:
The facility maintains reading material and games in the living room cabinet..

Emergency Phone Numbers/Exit Plan:
Posted in the entry way area and available for review.

Postings:
The See Something, Say Something (PUB475) was posted in the entry way and the Ombudsman Poster was in the hallway. The Rights of the Resident Councils, Resident's Rights, Theft & Loss Policy, and Activity Schedule, were posted on the bulletin boards above the desk.

Food Service and Menu:
Supply of seven day non-perishable and two day perishables were observed. The sample menu was available for review. The emergency food/water supply was available.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
LIC809 (FAS) - (06/04)
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