Serenity Home Care

Type of visit: Prelicensing

On July 27, 2023, following a Pre-Licensing inspection, Licensing Program Analyst, Dwayne Mason Jr. assigned three corrections for Administrator (AD) Annette Winters to complete by close of business (COB) August 28, 2023 in order to be ready for licensure. LPA returned to the facility on August 9, 2023 and was granted entry to the facility by the AD at 8:30am. LPA discussed with the AD the purpose of the visit. LPA is conducting a follow-up Pre-Licensing visit with the purpose of verifying the following corrections: 1. Closet doors in Resident Bedrooms must be replaced with appropriately functional doors. 2. The garage window with a hole in it needs to be replaced. 3. Hot water dispensed in the bathrooms must measure between 105 and 120 degrees Fahrenheit Upon inspection, LPA observed that: 1. Closet doors in Resident Bedrooms were replaced with appropriately functional doors. 2. The garage window with a hole in it was replaced with a new window 3. Hot water dispensed in the bathrooms measured between 105 and 120 degrees Fahrenheit. Hot water measured at 115.7 degrees Fahrenheit in the bathroom between the Master Bedroom and Bedroom 2. Hot water measured at 116.4 degrees Fahrenheit in the Master Bathroom. The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. Exit interview was conducted and a copy of this report was provided to designated AD.the state’s words, verbatim · CDSS document, Aug 9, 2023

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Dwayne Mason Jr. made an announced inspection to the facility for purpose of conducting a pre-licensing inspection. LPA arrived at the facility at 9:05am and was greeted and granted entry by designated Administrator (AD) Annette Winters. An application to operate a Residential Care Facility for Elderly (RCFE) for (6) capacity, (0) ambulatory, (6) non-ambulatory, and (0) bedridden clients was received by Community Care Licensing (CCL) on 3/22/2023. Structure: The facility is a one-story home with three resident bedrooms, two bathrooms, living room, kitchen, dining room, family room, an attached two car garage, backyard, porch and a crawl-space accessible through a pull-down ladder in the hallway. Photos of the pull-down ladder leading to the crawl-space were taken. LPA observed the crawl-space to be empty. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in one of the living room. There is a back yard with one exit gate on Northeast side of the house. There is one shaded seating area in the backyard. LPA did not observe any obstacles or hazards in the backyard. LPA observed a hole in one of the garage windows facing the backyard. Applicant must replace this window by the assigned due date in order to be ready for licensing. Client Bedrooms: All resident bedrooms had the required furnishings. LPAs observed all resident beds had linens and blankets. LPA observed all windows were screened. LPA observed closet doors in all resident rooms to be inoperable. The applicant will replace all closet doors by the assigned due date in order to be ready for licensing. Toxins: LPA observed chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to client and will be stored and locked in closet in the hallway. Medications, First-Aid Kit & Book: Medication will be stored in a locked closet in the hallway. First aid kit is stored in the same locked closet. The first aid kit has all the required elements. Resident & Staff Files: Records will be kept locked in the closet in the hallway. Fire Extinguisher: LPA observed the fire extinguisher to be fully charged as indicated by the arrow pointing in the green zone. LPA observed a receipt of purchase for the fire extinguisher which indicates the fire extinguisher was purchased on 2/27/23. Reading Material, Games, Equipment & Materials: The facility has activity materials that will be kept on in the living room and family room. Materials for resident use include puzzles, card games, other games and books. Fire clearance: Was approved by a fire inspector of Orange County Fire Authority on 06/20/2023. Component III: Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements. Bathrooms: All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 122 degrees Fahrenheit in the bathroom between the Master Bedroom and Bedroom 2. Hot water measured at 121.5 degrees Fahrenheit in the Master Bathroom. The applicant must have the water temperature adjusted to between 105 and 120 degrees Fahrenheit by the assigned due date in order to be ready for licensing. Linens & Hygiene Supplies: A supply of extra linen was stored in closets in the hallway. Emergency Phone Numbers, Exit Plan & Menu: Posted and available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Food Service: There is a supply of 2-day perishable and 7-day of non-perishable food on hand. Smoke Detectors: Smoke detectors were observed to be dual Smoke & Carbon Monoxide detectors that are stationed throughout the home. The dual detectors were tested and observed to be operational. Appliances: Gas five burner stove with 1 oven, 1 refrigerator, dish washer, microwave, washer, and dryer are operational. The following corrections are needed before applicant is ready for license: 1. Closet doors in Resident Bedrooms must be replaced with appropriately functional doors. 2. The garage window with a hole in it needs to be replaced. 3. Hot water dispensed in the bathrooms must measure between 105 and 120 degrees Fahrenheit The due date for these corrections are Monday, August 28, 2023 by close of business (COB) Exit interview was conducted and a copy of this report was provided to designated AD.the state’s words, verbatim · CDSS document, Jul 27, 2023

Type of visit: Office

Component II completion: Successful Facility Type: RCFE Application Type: INITIAL Capacity: 6 Census (if any clients in care): 0 COMP II Participants: Annette Winters - CEO/Administrator Interview Method: Telephone interview On July 12, 2023, Applicant/Administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of the following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-Licensing Readinessthe state’s words, verbatim · CDSS document, Jul 12, 2023