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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608600
Report Date: 09/14/2025
Date Signed: 09/14/2025 03:27:26 PM

Document Has Been Signed on 09/14/2025 03:27 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:SERENE LIFE SENIOR CAREFACILITY NUMBER:
197608600
ADMINISTRATOR/
DIRECTOR:		SAMUEL C. TANFACILITY TYPE:
740
ADDRESS:11221 LULL STREETTELEPHONE:
(818) 308-6578
CITY:SUN VALLEYSTATE: CAZIP CODE:
91352
CAPACITY: 6CENSUS: 5DATE:
09/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:09 PM
MET WITH:Rima Abelian - AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Jose Tan, met with Administrator Rima Abelian for a One (1) Year Required visit for this facility. LPA explained the reason for the visit.

A tour of the physical plant was conducted at 12:22 PM and the following was noted:

There is only one entrance being utilized at the facility. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Infection Control and Mitigation plan. The facility has a designated visitors' area at the backyard.

The facility has a total of four (4) bedrooms and three (3) bathrooms. One (1) of the bathroom is designated for staff use only. The facility is fire cleared for six (6) non ambulatory residents, one (1) of which maybe bedridden on Room #3. Hospice Waiver for two (2) residents.

KITCHEN: The facility has a Kitchen that is equipped with a refrigerator, microwave, stove, dishwasher and sink. There was an adequate supply of perishable and nonperishable food. Knives were observed locked in a kitchen drawer. Cleaning supplies and other toxins are stored in the cabinet in the bedroom hallway which was locked during visit.
BEDROOMS: There are three (3) shared bedrooms for clients' use and two (2) bedroom for designated for staff use. The residents' bedrooms are furnished with beds, night stand, chairs, dressers, bedding and linen and have sufficient lighting and storage. (continued on LIC 809-C)
NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Jose Gary Tan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SERENE LIFE SENIOR CARE
FACILITY NUMBER: 197608600
VISIT DATE: 09/14/2025
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(continued from LIC 809)

BATHROOMS: The facility has three(3) bathrooms, two (2) are designated for staff use only. The bathroom was observed to have the proper fixtures, grab bars, and non-skid mats. The hot water temperature was measured at 105.6°F.

LAUNDRY ROOM: The laundry room is located adjacent to the kitchen. Laundry detergents and other cleaning agents were locked in a cabinet in the laundry area. The cleaning supply cabinet was observed to be locked during visit.



COMMON AREAS: These included the living room and the dining area. Living room was furnished with chairs and side tables. The living room area was furnished with a television. There was no visible immediate hazards. Dual smoke/carbon monoxide alarms were tested and observed to be operable. Fire extinguisher was last serviced on 01/22/25 and located in the dining room area. The facility is equipped with closed circuit television system in the outside surroundings and common areas only.

MEDICATIONS: The medication cabinet is located in the bedroom hallway adjacent to the living room and observed to be locked during visit. A complete first aid kit is located in the kitchen.

Resident Records: All residents record were reviewed and observed to be complete and updated. Staff records were also reviewed and observed to be complete and updated.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. All entry and exit doors have a functional auditory alert when the doors open. The front yard of the facility has a covered patio and outdoor furniture to accommodate the residents. The Garage is currently being used as frozen foods, PPE and other supplies storage. There are two (2) tool shed on the backyard separated by a 5' gate and inaccessible to residents. There is a drive way in side of the facility which could park three (3) cars at a time. There is no body of water in the facility.

Disaster drill was last conducted on 07/01/25. Required posting observed in facility (complaint hot line poster). Exit interview conducted. Copy of this report issued.
NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Jose Gary Tan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2025
LIC809 (FAS) - (06/04)
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