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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603894
Report Date: 12/17/2024
Date Signed: 12/17/2024 12:35:32 PM

Document Has Been Signed on 12/17/2024 12:35 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SERENITY VILLAFACILITY NUMBER:
374603894
ADMINISTRATOR/
DIRECTOR:
SHANEL PRONOVOSTFACILITY TYPE:
740
ADDRESS:228 IRON DRIVETELEPHONE:
(760) 758-9990
CITY:VISTASTATE: CAZIP CODE:
92083
CAPACITY: 6CENSUS: 4DATE:
12/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Camille Morales-AdministrationTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Debbie Palacios conducted an unannounced one (1) year required visit. LPA was granted entry by caregiver, Sheila Amoranto and Administrator Camille Morales who were informed of the purpose of the visit. At the time of the visit, there were four (4) residents present. Administrator and Caregiver present were observed to have obtained proper fingerprint clearance and were associated to the facility. LPA Palacios observed the following during today's visit:

LPA Palacios conducted a tour of the facility with caregiver, Sheila. The physical plant is a single story structure that contained four (4) resident bedrooms, three (3) staff bedrooms, and three (3) resident bathrooms. The facility has a (1) formal dining room, kitchen, living room, laundry room and a gated backyard. Indoor and outdoor passageways were free of obstruction. There were no bodies of water located on the property. The facility has more than a two (2) day supply of perishable food and seven (7) day supply of non-perishable foods. Extra linen were observed in the main bathroom cabinet. Dishes and utensils were in sufficient supply and in good repair. Knives and sharp items were observed in a locked cabinet in the kitchen and cleaning supplies were locked under the sink cabinet. Resident bedrooms had the required bedding, furniture, and lighting. The smoke and carbon monoxide detectors were tested and were observed to be operable. Centrally stored medication was observed in a locked cabinet in the kitchen. The outdoor patio was observed to have shaded seating to encourage outdoors socialization. Two (2) fully charged fire extinguishers were observed in the facility dated 05/20/24. The facility was observed to be in a clean condition; free of dirt, insects, rodents, and pests.

Staff files reviewed include but not limited to have personnel records, health screenings, criminal record clearance, required training, and valid first aid/CPR certification. Resident files included but are not limited to signed admission agreements, pre-placement, personal rights, needs and service plans, and updated physician reports. Facility sketch, LTCO, CCL complaint poster, Exit signs, license and emergency disaster plan were posted on the walls.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Debbie Palacios
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SERENITY VILLA
FACILITY NUMBER: 374603894
VISIT DATE: 12/17/2024
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LPA reviewed the facility's Fire and Emergency Drill logs and noted the facility's last fire drill was conducted on 11/18/24.

During today's visit, LPA did not issue any citations. An exit interview was conducted and a copy of this report was reviewed and provided.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Debbie Palacios
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC809 (FAS) - (06/04)
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