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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607301
Report Date: 09/08/2022
Date Signed: 09/08/2022 04:09:58 PM


Document Has Been Signed on 09/08/2022 04:09 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:SERENITY SENIORS HOME IFACILITY NUMBER:
197607301
ADMINISTRATOR:MAYA K. ASTIERFACILITY TYPE:
740
ADDRESS:217 S. ESSEY AVE.TELEPHONE:
(310) 763-7879
CITY:COMPTONSTATE: CAZIP CODE:
90221
CAPACITY:10CENSUS: 4DATE:
09/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:47 PM
MET WITH:Tyshala Law DSPTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Jeremiah Randle conducted an unannounced Annual inspection visit and infection control inspection to the above facility. LPA was met by Tyshala Law DSP the purpose of today’s visit was explained. There are currently (4) Regional Center consumers in placement. All (3) clients are ambulatory 1 Client is non ambulatory. The facility is a single-story structure located in a residential neighborhood. It consists of the following: 5 bedrooms, 6 bathrooms, family room/office, living room, kitchen, dining room, shaded area, indoor and outdoor activity area, laundry room and detached garage.

LPA and Administrator Antoinette Richardson toured the entire facility inside and out. Documents are posted as mandated by the DPH and CCLD. Bedrooms 1 – 5 are occupied by clients one bedroom is vacant, all contained the mandated furniture. The (6) bathrooms are clean and operational. Smoke detectors and carbon monoxide detector are in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients. 1 staff file is current, 1 resident file is current along with medications. The water temperature is at 120 degrees. A comfortable temperature is maintained in the facility. Ample supply of perishable and nonperishable food, linens and personal hygiene supplies are adequate, hazardous toxins and/or items are inaccessible to clients, 2 fire extinguishers are charged. First Aid kit complete and with manual. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, sanitizer/soap in the staff bathroom and additional sanitation supplies in a locked cabinet located in the garage. LPA observed staff and clients wearing masks, clients can isolate in their room if necessary required postings throughout the facility. The administrator advised LPA that sanitizer is administered to client with the supervision of staff, but sanitizers are not kept in their rooms for safety reasons. The facility has an approved Mitigation plan staff has been N95 fit tested. Visitors are logged and checked. The client’s temperatures are checked and logged 2x a day.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview conducted with Antoinette Richardson Administrator and copy of report provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 395-3554
LICENSING EVALUATOR NAME: Jeremiah RandleTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022
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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