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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006899
Report Date: 03/13/2026
Date Signed: 03/13/2026 11:33:07 AM

Document Has Been Signed on 03/13/2026 11:33 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:1 SERENITY SENIOR CARE HOMEFACILITY NUMBER:
306006899
ADMINISTRATOR/
DIRECTOR:		SANSANO, MINERVAFACILITY TYPE:
740
ADDRESS:24492 FERROCARRILTELEPHONE:
(949) 600-7757
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 0DATE:
03/13/2026
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Applicant Minerva SansanoTIME VISIT/
INSPECTION COMPLETED:
11:40 AM
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On March 13, 2026 Licensing Program Analyst (LPA) Garlli Tat conducted a scheduled pre-licensing visit to the facility and was greeted and granted entry by applicant Minerva Sansano. LPA reviewed the Administrator's Certificate that expires on April 9, 2026.

LPA toured the exterior and interior portion of the facility with Minerva Sansano.

Facility is a single level home. On February 18, 2026, The Orange County Fire Authority granted fire clearance for a capacity of six residents (five of which may be non-ambulatory, one may be bedridden, and a request for hospice waiver for six has been submitted for review). There are a total of five bedrooms, two of which are private resident bedrooms, two are shared resident bedrooms, and one staff bedroom. There is a garage that is utilized for storage.

All bedrooms were provided with furniture, in good repair, clean linens, adequate storage space, and kept hazard free. The bathrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in residents' bathrooms were measured between 109.5 to 110.4 degrees Fahrenheit.

Adequate supply of brand new linens are stored in the hallway. LPA observed the PUB475 "See Something, Say Something" poster posted by the front entrance. Emergency disaster plan and Personal Rights are posted by the front entrance. Sharp items and knives will be locked in the kitchen drawers. Facility had back-up emergency food and water supply located in the garage.

Continued on LIC 809-C.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Garlli Tat
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2026
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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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: 1 SERENITY SENIOR CARE HOME
FACILITY NUMBER: 306006899
VISIT DATE: 03/13/2026
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Wired smoke and carbon monoxide detectors were tested and operational. All auditory exit alarms were tested and observed to be operational. Fire extinguisher was fully charged, mounted, located in the kitchen, and was purchased on January 12, 2026.

Stove is a five burner gas stove that lights unassisted, and there is single oven, dishwasher, refrigerator and freezer. Washer and dryer are located in the garage. All appliances were operational. There is a locked cabinet underneath the kitchen sink for toxins.

LPA observed that First-Aid kit had all the required components. Medication cabinet was observed in the kitchen. Applicant will keep this locked at all times.

There is one exit gate in the backyard, which is self-latching and self-closing.

Binders will kept in a locked cabinet located in the kitchen for resident and staff files. The facility has activities that commensurate with plan of operation.

LPA reviewed the Component III with applicants, Minerva Sansano and Daisy Pascua.



All items reviewed during the visit are in compliance. Facility appears to be ready for licensure. The applicant was notified that the final application approval will be issued by Centralized Applications Bureau (CAB).

LPA conducted an exit interview with Minerva Sansano and a copy of this report was reviewed and provided to the facility.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Garlli Tat
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2026
LIC809 (FAS) - (06/04)
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