197608815-12-13-2023-31-AS-CALH-CYGTF6-20231213134102

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608815
Report Date: 12/13/2023
Date Signed: 12/13/2023 01:41:43 PM

Document Has Been Signed on 12/13/2023 01:41 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 NATURE ASSISTED LIVING		FACILITY NUMBER:	197608815
ADMINISTRATOR:	SAMUEL C. TAN		FACILITY TYPE:	740
ADDRESS:	10987 LUDDINGTON STREET		TELEPHONE:	(818) 253-5989
CITY:	SUN VALLEY	STATE: CA	ZIP CODE:	91352
CAPACITY:	6	CENSUS: 6	DATE:	12/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	RIma Abelian		TIME COMPLETED:	01:40 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

On 12/13/2023 at 9:00 AM Licensing Program Analyst (LPA) Christopher Alemoh conducted an unannounced Required – Annual Continuation Inspection and met with Rima Abelian, Administrator. Five (5) residents and two (2) staff were present during this inspection.

Facility is licensed to serve six (6) non-ambulatory residents. The facility also has an approved hospice waiver for two (2) residents. The facility currently has 6 non-ambulatory residents. The Annual Licensing Fees are current.

The home consists of 1 floor level with: 1 staff room, 3 resident rooms, 4 restrooms, kitchen, dining room, laundry room.

At 09:15AM LPA conducted a physical plant tour.

The administrator accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards.

Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises.

Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, hot water temperature properly measured between 112.5-113.1 F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked.

Common areas were clean and clear of hazards, doorways were free of obstructions.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Christopher Alemoh	TELEPHONE: 818-669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023

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 NATURE ASSISTED LIVING	FACILITY NUMBER: 197608815
	VISIT DATE: 12/13/2023

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

LPA toured the kitchen area and observed a two day supply of perishable and a seven day supply of non-perishable food. Knives and toxics were kept in a locked storage cabinet. First Aid kit was available. This facility has two (2) fire extinguisher, last serviced November 23,2022, LPA observed one extinguisher located in the kitchen and second extinguisher in the living room. LPA tested all carbon monoxide detectors and smoke detectors located in the kitchen area. Both devices were functional. LPA observed that all bedrooms and hallways are equipped with a carbon monoxide and smoke detector.

At 10:10 AM LPA conducted a file review.

4 staff records were reviewed, 4 out of 4 staff records had current first aid certificates and had required criminal record clearances or criminal record exemptions.

6 resident records were reviewed and, 6 out of 6 client records had Admission Agreements, Medical Assessments, Pre-appraisals (or Reappraisals) and/or Needs & Services Plans.

An exit interview was conducted. A copy of this report and appeal rights were discussed and left with Administrator Rima Abelian.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Christopher Alemoh	TELEPHONE: 818-669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2