197608600-9-26-2024-31-AS-LDLC-D9H2V4-20240926174321

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608600
Report Date: 09/26/2024
Date Signed: 09/26/2024 05:43:44 PM

Document Has Been Signed on 09/26/2024 05:43 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
WOODLAND HILLS S.RO, 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:	09/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Rima Abelian, Administrator		TIME COMPLETED:	03:15 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA), Leizl de la Cerra, conducted an unannounced annual inspection at the facility mentioned above. At 10:45am LPA was greeted by the Administrator and LPA explained the reason for the visit. Administrator granted LPA access to the facility.
At 11:15am, LPA conducted a tour of the facility and the following was observed:

Bedrooms: The facility has a total of five (5) bedrooms. Three (3) bedrooms are designated for the residents. LPA observed all bedrooms are properly furnished and clean. The beds have appropriate bedding and linens. All rooms have sufficient lighting.

Bathrooms: LPA observed all bathrooms to be clean and in good repair. Well stocked with toilet papers, soap and paper towels. LPA observed the appropriate grab bar and non-skid mat. LPA observed appropriate hand washing signs posted in each bathroom. All trash cans observed to have fitted lids to protect from cross contamination. The hot water temperature measured at 107°F.

Common Areas: The facility maintains a comfortable temperature at 73°F. The living room and dining area appeared clean and were properly furnished. No obstructions and or tripping hazards observed. There is a fire extinguisher by the dining area observed to be operational.

Kitchen: The kitchen appliances were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found enough food for at least three (3) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Knives were stored in a locked drawer in the kitchen. Food preparation areas are clean. Garbage cans have tight fitting covers. Kitchen cleaning supplies were stored in a locked cabinet.

Laundry Area: This is located by the kitchen area. There is a functioning washer and dryer. Laundry detergents and cleaning solutions were stored in locked cabinets.

CONTINUE to LIC809C

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Leizl De La Cerra	TELEPHONE: (818) 454-0632
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SERENE LIFE SENIOR CARE	FACILITY NUMBER: 197608600
	VISIT DATE: 09/26/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Residents Records: LPA reviewed files for six (06) out of six (06) residents. Files are maintained at the facility in a locked room. Medications were reviewed for one(01) resident to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubbled packed. Medications are in a locked cabinet attached to a wall.

Smoke detectors/carbon monoxide. Smoke detectors were located throughout the facility, and 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, 11:55am LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. LPA observed three sheds at the back separated by a vinyl fence. LPA observed the fence was locked and inaccessible to residents in care. All sheds locked and inaccessible to clients in care. All sheds are used for an extra storage. There are no bodies of water at this facility.

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.

Operational Requirements: Liability Insurance policy is valid and will expire on 07/09/2025. Surety Bond (Tokio Marine/American Contractors Indemnity Company)is in effect with bond amount of $3,000.00 with expiration of 10/30/2025. The fire clearance is approved on 2/05/2014 for one (1) bedridden room. Fire drill was last conducted on 7/01/2024. The First Aid Kit is complete and current. Fire inspection completed on 11-03-2023.

The facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed during today’s visit. Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Leizl De La Cerra	TELEPHONE: (818) 454-0632
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2