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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006712
Report Date: 08/05/2025
Date Signed: 08/05/2025 02:56:45 PM

Document Has Been Signed on 08/05/2025 02:56 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:GENTLE SERENITYFACILITY NUMBER:
306006712
ADMINISTRATOR/
DIRECTOR:		AZIZI, KHOJESTAFACILITY TYPE:
740
ADDRESS:25475 ADRIANA STREETTELEPHONE:
(949) 305-5259
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
08/05/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:43 PM
MET WITH:Facility Administrator- Khojesta Azizi TIME VISIT/
INSPECTION COMPLETED:
03:25 PM
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Licensing Program Analysts (LPAs) Celine Rodriguez and Garlli Tat conducted an announced visit for the purpose of conducting the Pre-Licensing visit for a Change of Ownership (CHOW). LPAs conducted the visit with Applicant/Administrator (AD) Khojesta Azizi. The initial application to operate a Residential Care Facility for the Elderly (RCFE) was received by the Department of Social Services on July 29, 2025 for age range 60 and over, of which 6 may be on hospice, 5 may be non-ambulatory, and 1 bedridden. For this visit, there are a total of 6 residents in care.

Structure: Facility is a single level structure. On 3/18/2025, The Orange County Fire Authority granted a fire clearance for a capacity of 6 residents (which 5 may be non-ambulatory, and 1 may be bedridden). There are a total of 7 bedrooms, which 6 are private resident rooms and 1 room designated for staff.

Bedrooms: All bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept hazard free.

Bathrooms: There are a total of 3 restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature was measured to be at 118.4 degrees Fahrenheit.

Linens and Hygiene Supplies: Adequate supply of linens is stored in the hallway cabinet.

Posters, Emergency Phone Numbers, Exit Plan: LPAs observed the PUB475 "See Something, Say Something" poster, emergency disaster plan, and administrator certificate for Khojesta Azizi which expires on July 17, 2026. These were posted at the main entrance.

Continued on LIC809-C...

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Celine Rodriguez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: GENTLE SERENITY
FACILITY NUMBER: 306006712
VISIT DATE: 08/05/2025
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Food Service and Menu: Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to the residents in care. Facility had back-up emergency food and water supply located in the pantry.

Smoke and Carbon Monoxide Detectors: Smoke and carbon monoxide detectors were tested and operational.

Alarms: There are auditory alarms located on all exit doors of which all were tested and operational.

Fire Extinguisher: Fully charged, mounted, and located in the kitchen and tagged for 2025.

Appliances: Stove is a four-burner induction stove, and there is single oven, dishwasher, refrigerator and freezer. Washer and dryer are located inside the garage.

Toxins: Locked and inaccessible to residents.

Medications, PPE First-Aid Kit and Manual: LPAs observed that First Aid Kit had all the required components. Medications were locked in a cabinet located in the kitchen.

Backyard: No bodies of water were observed. There are 2 exit gates in the backyard, of which both are self-closing and self-latching.

Resident and Staff Files: Records were kept in a locked cabinet located in the kitchen.

Recreational Activities: The facility has activities that commensurate with plan of operation.



LPA Rodriguez reviewed the Component III with AD Azizi.

Per interviews, Licensee/Administrator stated that they are not planning to advertise for special dementia program for this facility as of this time.

Pre-licensing visit and Component III are now complete. LPAs will provide copy of this report to Centralized Applications Bureau for review and final determination of the application. LPAs advised AD Azizi to utilize the main office email: CCLASCPOrangeCountyRO@dss.ca.gov for additional inquiries. LPAs conducted an exit interview with AD Azizi, and a copy of this report was provided to the facility.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Celine Rodriguez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
LIC809 (FAS) - (06/04)
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