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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608600
Report Date: 08/18/2021
Date Signed: 08/31/2021 12:19:01 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:SERENE LIFE SENIOR CAREFACILITY NUMBER:
197608600
ADMINISTRATOR:SAMUEL C. TANFACILITY TYPE:
740
ADDRESS:11221 LULL STREETTELEPHONE:
(818) 308-6578
CITY:SUN VALLEYSTATE: CAZIP CODE:
91352
CAPACITY:6CENSUS: 6DATE:
08/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Rima AbelianTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Angelica Arambulo conducted an unannounced required annual visit to facility. LPA met with the Licensee administrator of the home Rima Abelian.
LPA was given a tour of the faciity.

Upon entry to the facility there were COVID signs regarding visiting, hand sanitizing and monitoring symptoms. The Staff was not wearing her mask and put one on before LPA entered facility. LPA was screened at the door for Covid, and temperature was taken. The dining table had piles of folders which were left unattended. Rima said she was working on them. The Mitigation plan was on hand which was approved on 4-27-2021.

There was a 30 day supply of PPE, hand sanitizers and mask. All residents were resting in their rooms at the time. Some had a mask on and some did not. All of are not attending day program during this time.

No obstructions observed at any entry way, Rooms were organized and common areas observed clean. There are two staff rooms and extra bathroom which can be altered to accommodate anyone who may be Covid positive. All residents are vaccinated. Staff are still deciding if they want the vaccine.

No citations issued. report signed and issued to administrator. Email on file needs to be updated.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Angelica ArambuloTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021
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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