197607301-12-2-2023-11-AS-RCLD-CY5UPE-20231202144526

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607301
Report Date: 12/02/2023
Date Signed: 12/02/2023 02:45:33 PM

Document Has Been Signed on 12/02/2023 02:45 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	SERENITY SENIORS HOME I		FACILITY NUMBER:	197607301
ADMINISTRATOR:	MAYA K. ASTIER		FACILITY TYPE:	740
ADDRESS:	217 S. ESSEY AVE.		TELEPHONE:	(310) 763-7879
CITY:	COMPTON	STATE: CA	ZIP CODE:	90221
CAPACITY:	10	CENSUS: 5	DATE:	12/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Maya Astier		TIME COMPLETED:	02:50 PM

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On 12/02/2023 at 12:15PM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced Required – Annual Inspection and met with Licensee Maya Astier. Five (5) residents and three (3) staff were present during this inspection.

Facility is licensed to serve 9 non-ambulatory and 1 bedridden elderly residents age 60 and above. Facility may accept or retain 1 resident on hospice. The facility currently has five residents.

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.

Staff accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards.

Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises.

Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, hot water temperature properly measured at 119F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked.

Common areas were clean and clear of hazards, doorways were free of obstructions.

Continue to LIC809-C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SERENITY SENIORS HOME I	FACILITY NUMBER: 197607301
	VISIT DATE: 12/02/2023

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LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxics were kept in locked storage cabinet. First Aid kit was available. Fire extinguisher, last serviced July 23, 2023 was observed in the kitchen area. LPA tested all carbon monoxide detectors and smoke detector located in the facility. Both devices were functional.

5 staff records were reviewed, 5 out of 5 staff records had current first aid certificates and had required criminal record clearances or criminal record exemptions. Two staff interviews were conducted.

5 resident records were reviewed and, 5 out of 5 client records had, Medical Assessments. Two residents’ medications was reviewed. Two residents were interviewed.

No deficiencies are being cited.

An exit interview was conducted, and technical assistance provided. A copy of this report was discussed and left with Maya Astier.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2023

LIC809 (FAS) - (06/04)

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