197608600-7-5-2022-31-AS-TCAS-CG2PS5-20220705113347

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608600
Report Date: 07/05/2022
Date Signed: 07/05/2022 11:34:48 AM

Document Has Been Signed on 07/05/2022 11:34 AM - 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	SERENE LIFE SENIOR CARE		FACILITY NUMBER:	197608600
ADMINISTRATOR:	SAMUEL C. TAN		FACILITY TYPE:	740
ADDRESS:	11221 LULL STREET		TELEPHONE:	(818) 308-6578
CITY:	SUN VALLEY	STATE: CA	ZIP CODE:	91352
CAPACITY:	6	CENSUS: 6	DATE:	07/05/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Rima Abelian		TIME COMPLETED:	11:40 AM

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Licensing Program Analyst (LPA) Tuesday Cabiness conducted an unannounced infection control inspection/visit. Upon arriving, LPA was greeted outside by Administrator Rima Abelian, who allowed LPA to enter the facility. According to Rima, there have not been any active or past COVID cases at the facility, and has been COVID free since the beginning of the pandemic. There are currently (5) residents vaccinated, and (1) who refused. There are (2) staff vaccinated; no-one from the facility has received the booster shot. The current census is (6). LPA and Administrator entered through the front door of the facility, and temperature was taken, and LPA observed the visitors sign in sheet and cleaning table, with hand sanitizer. LPA observed staff to have full mask covering. COVID-19, CDC, Department of Public Health, and Licensing postings on the walls throughout the facility.

The infection control inspection began with the Administrator, who escorted LPA throughout the facility. There are (3) bathrooms, with hand-washing signs, and there are (6) bedrooms; with (1) room for staff and (1) room for Administrators. All bedrooms were properly furnished and common areas were observed to be clean, including bathrooms, with soap and towels. LPA conducted a mitigation plan and facility operation review with the Administrator.

The Administrator reported to LPA, the facility has documentation of all vaccination records and other pertinent information pertaining to COVID-19, in staff and resident files. All new employee hires and new resident admits, will be properly screened, and provided a negative COVID test before entering the facility. New hires are required to be vaccinated. Administrator reported they receive and reviews all the departmental emails and continues to provide and conduct training to staff in relation to COVID-19.

There is currently a paid sick leave policy in place. The facility does not have staffing issues, due to having a back-up staff available when needed.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 CARE	FACILITY NUMBER: 197608600
	VISIT DATE: 07/05/2022

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There is (1) designated room for potential positive COVID residents.

PPE supplies were inspected, and facility has an abundance of PPE supplies available. Chemicals, cleaning supplies, paper products were observed and locked and secured. Administrator informed LPA that they continue to implement the best practices for their facility, which has kept them COVID-19 free since the beginning of the pandemic. The facility is aware to report any changes with residents and staff to Licensing and there LPA, pertaining to positive COVID-19 cases.

Exit interview was conducted, and copy of report provided.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2022

LIC809 (FAS) - (06/04)

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