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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530342
Report Date: 09/22/2025
Date Signed: 09/22/2025 11:37:06 AM

Document Has Been Signed on 09/22/2025 11:37 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SENIOR SERENITY IN THE HIGH DESERTFACILITY NUMBER:
365530342
ADMINISTRATOR/
DIRECTOR:		RIVERA-VASQUEZ, MICHELLEFACILITY TYPE:
740
ADDRESS:17375 REDDING STTELEPHONE:
(760) 983-6136
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 6CENSUS: 0DATE:
09/22/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Michelle Rivera-VasquezTIME VISIT/
INSPECTION COMPLETED:
11:40 AM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore conducted an announced visit to complete the Pre-licensing inspection. LPA met with Administrator, Michelle Rivera-Vasquez, and discussed the purpose of the visit.

The application is for a Residential Care Facility for the Elderly (RCFE). A fire clearance was granted by San Bernardino County Fire department on 7/18/2025 for a total capacity of (6) non-ambulatory residents. LPA toured the interior and exterior areas of the facility. The following were inspected:

Physical Plant: The facility consist of three (3) resident bedrooms, one (1) staff room, three (3) bathrooms, laundry room, living room, kitchen/dining room and attached garage. The physical plant is consistent with floor plan submitted by the facility. Indoor and outdoor passageways were kept free of obstructions. The facility has no swimming pools or similar bodies of water. No firearms are stored at the facility. The facility is equipped with fire extinguishers, fire/carbon monoxide alarms, telephone service, and laundry equipment. The facility has sufficient bed linen, towels, and personal hygiene supplies. The facility has a storage area where resident and staff files will be kept. The facility has a locked room were sharps, cleaning solutions, and other toxins will be kept.

Resident Bedrooms: Resident bedrooms were equipped with clean mattresses/linens, nightstands, chairs, and lighting.

Resident bathrooms: Resident bathrooms were equipped with grab bars, non-skid mats, and operating bathroom equipment. The bathroom's hot water temperature tested at 111 degrees Fahrenheit.
NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Magda Malcore
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2025
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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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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SENIOR SERENITY IN THE HIGH DESERT
FACILITY NUMBER: 365530342
VISIT DATE: 09/22/2025
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Food Service/Dining Areas: Kitchen and dinings areas were kept clean and odor free. Utensils and dishware are in good repair and ready for resident use. The refrigerator temperature test at 40 degrees F. and freezer test at 0 degrees. The dining area located near the kitchen has sufficient space for resident use.

Medication: The facility has a locked box where medications will be stored.

Activities: The facility has sufficient indoor and outdoor space for activities. Backyard is equipped with a covered activity area and the facility is enclosed with gated fence.

Postings: The facility has posted in the entry area, emergency telephones, Community Care Licensing Complaint poster, Ombudsman poster, Resident Personal Rights, and Resident Council Rights.



Overall, the facility is clean and in good repair. The Pre-licensing inspection and Component III orientation are complete.

An exit interview was conducted where this report was discussed and a copy of this report was provided to Administrator Rivera-Vasquez at the conclusion of the visit.
NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Magda Malcore
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2025
LIC809 (FAS) - (06/04)
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