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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881623
Report Date: 01/06/2025
Date Signed: 01/06/2025 09:44:51 AM

Document Has Been Signed on 01/06/2025 09:44 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SERENE LEGACY LLCFACILITY NUMBER:
331881623
ADMINISTRATOR/
DIRECTOR:
ORTIZ, MONICAFACILITY TYPE:
740
ADDRESS:1508 PALERMO DRTELEPHONE:
(951) 231-5516
CITY:PERRISSTATE: CAZIP CODE:
92571
CAPACITY: 6CENSUS: 0DATE:
01/06/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Applicant, Monica OrtizTIME VISIT/
INSPECTION COMPLETED:
09:50 AM
NARRATIVE
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Licensing Program Anaylst (LPA) Janira Arreola conducted an announced Prelicensing Visit. LPA was granted entry by and met with, Applicant Monica Ortiz who was informed of the purpose of the visit.

The applicant is seeking an initial license for a Residential Care Facility for the Elderly, for ages 60 and above. The facility is a (2) story home with resident rooms on the first floor totaling (3) bedrooms and (2) bathrooms. All (3) bedrooms have been approved by the local fire jurisdiction for (6) non-ambulatory residents. There are no bodies of water, weapons or fire arms kept at the facility.

LPA observed the kitchen had cooking supplies and equipment in good working condition. The facility meets the (2) day perishable and (7) day non-perishable supply of food. The knifes and cleaning supplies will be kept locked in the laundry room. The medications will be kept in a locked cabinet in the kitchen. The outdoor area was observed to be free of hazards and has an emergency exit. There are activity supplies for future residents to engage in in the entry way. LPA observed the resident bedrooms had the required furniture and the bathrooms have grab bars and hygiene supplies for future residents. The hot water temperature was recorded at 118F and the carbon monoxide and smoke alarms are in working condition. The laundry room had cleaning supplies to do regular cleaning of the facility, and equipment in good working condition. There is a supply of linens and towels for future residents. The facility has areas designated for future staff and resident records. Required postings are found in the dinning room, and emergency and PPE supplies were kept in a hallway closet. The facility phone number is operational at (951) 627-5930.

There are no objections for the applicant to proceed in the prelicensing process. An exit interview was conducted where this report was reviewed and provided to the applicant.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2025
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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