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Inspection visit

Routine inspection

SERENE LEGACY LLCLicense 3318816233 citations on this visit
3 citations recorded

Inspector’s narrative

What the inspector wrote

Licensing Program Analysts (LPAs) Janira Arreola and Aziz Faizi conducted an unannounced annual required visit. LPA was granted entry and met with Administrator, Monica Ortiz, who was informed of the purpose of the visit. At the time of the visit there was (2) staff and (2) residents present. The facility is a one story home with (4) resident bedrooms and (2) bathrooms. No pools or firearms are housed at the facility. The facility is approved for (6) non ambulatory residents. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area and passage ways were observed to be free of hazards. LPA observed hygiene supplies for residents, PPE, clean linens. There are designated locked areas for sharps, dangerous objects, cleaning supplies, and medications. During the visit LPAs observed unlocked cleaning supplies and gardening tools in the back yard and unsecured knife in the kitchen. A deficiency was documented and plan of correction was created. The smoke detector and carbon monoxide are operational, and the hot water temperature 118F. There are emergency supplies such as emergency lighting, complete first aide kit and emergency food and water. LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. LPA reviewed the facility's emergency and disaster plan and infectious control plan. The facility has conducted a fire drill but did not document it, there a deficiency was cited and a plan of correction was created. Required postings were found in the facility. The listed administrator, possesses a current administrator's certificate. LPA reviewed (2) staff files and training. All staff have criminal clearance. (1) staff did not have updated CPR/First Aid Certification and did not have a health screening on file A deficiency was issued for completion of the staff's file. LPAs provided the licensee a copy of the LIC311F with all required forms to keep in resident and staff files. The Two (2) resident files were reviewed, and possessed all required paperwork. No resident's personal and incidental funds are being handled by the facility. LPA observed resident medications which are locked, filled, and stored in their originally received containers. The medication was accounted for on Centrally Stored Medication logs for residents. Technical Support services were offered and the licensee agreed to a referral for the program. An exit interview was conducted where this report was reviewed and provided.

Citations

3 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 1569.695(c)Type B

    Based on interview and record review, the licensee did not comply with the section cited above with fire drill that had not been documented which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87309(a)(1)Type B

    Based on (interview and record review the licensee did not comply with the section cited above with knife, gardening shears and cleaning supplies that were unlocked which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87412(a)Type B

    Based on interview and record review, the licensee did not comply with the section cited above with staff who did not have health screening tb test documented, or cpr training which poses/posed a potential health, safety or personal rights risk to persons in care.

FAQ · About this visit

Common questions about this visit

What happened during the January 29, 2026 inspection of SERENE LEGACY LLC?

This was a inspection inspection of SERENE LEGACY LLC on January 29, 2026. 3 citations were issued: 3 Type B.

Were any citations issued to SERENE LEGACY LLC on January 29, 2026?

Yes, 3 citations were issued (0 Type A, 3 Type B). The first citation was for: "Based on interview and record review, the licensee did not comply with the section cited above with fire drill that had ..."

What type of inspection was this?

This was a inspection inspection. inspection inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.