197608600-11-1-2023-31-AS-APAA-CX6RN8-20231101130954

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608600
Report Date: 11/01/2023
Date Signed: 11/01/2023 01:10:21 PM

Document Has Been Signed on 11/01/2023 01:10 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, 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: 5	DATE:	11/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Rima Abelian, Administrator		TIME COMPLETED:	01:40 PM

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At 10:20am Licensing Program Analyst (LPA), Angela Panushkina, conducted an unannounced annual inspection at the facility mentioned above. LPA was greeted by the Administrator, who granted access to the facility. Entrance interview conducted and LPA explained the reason for the visit.

At 10:30am, LPA conducted a tour of the facility and the following was observed:

Kitchen: LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents.

Bedrooms: The facility has five bedrooms of which three (3) bedrooms designated for residents use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Auditory alarms were tested and observed to be operational.

Bathrooms: At 10:40am LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured at 109°F. LPA observed appropriate grab bar and non-skid mat. LPA observed appropriate hand washing signs posted in each bathroom. All trash cans in bathrooms had fitted lids to protect from cross contamination.

Common Areas: The facility maintains a comfortable temperature at 69°F. The living room and dining area appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. There is a fire extinguisher by the dining area observed to be operational.

Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SERENE LIFE SENIOR CARE	FACILITY NUMBER: 197608600
	VISIT DATE: 11/01/2023

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Medications: At approximately, 10:50am LPA observed medications are centrally stored and locked in the cabinet, by the living room area and inaccessible to residents in care.

Smoke detectors/carbon monoxide. Smoke detectors were located throughout the facility, and at 11:00am they were tested and observed to be operational. Carbon monoxide was located by the entrance and was also tested and observed to be operational.

Outside areas: At approximately, 11:15am LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. LPA observed two sheds on the other side of the vinyl fence. LPA observed the fence was locked and inaccessible to residents in care. Upon entry to the other side LPA also observed all sheds locked and inaccessible to clients in care. All sheds are used for an extra storage. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. There are no bodies of water.

The garage: Detached garage was located in the back of the facility and kept locked and inaccessible to residents. Extra PPE supplies and food storage was also observed.

Administrative: LPA collected Certificate of Liability Insurance and LIC.500.

Between 11:30am to 1:00pm, LPA reviewed records of five (5) residents and three (3) staff. Resident and staff records appeared to be complete and updated.

Administrative: LPA collected Certificate of Liability Insurance and LIC500.

No citations issued during this visit. Exit interview conducted. Copy of report emailed to Licensee.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

LIC809 (FAS) - (06/04)

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