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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609368
Report Date: 11/09/2022
Date Signed: 11/09/2022 02:36:30 PM

Document Has Been Signed on 11/09/2022 02:36 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:SERENITY VILLA ASSISTED LIVINGFACILITY NUMBER:
197609368
ADMINISTRATOR:MARTINEZ, JERRILYNFACILITY TYPE:
740
ADDRESS:43126 FENNER AVETELEPHONE:
(661) 557-3434
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6CENSUS: 4DATE:
11/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Fracisco MartinezTIME COMPLETED:
02:50 PM
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On 11/09/2022 at 12:15 p.m. Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced required annual visit it to the facility. LPA was greeted by Licensee Francisco Martinez and was granted access. LPA explained the reason for the visit. LPA reviewed the facility has an approved mitigation plan approved 02/27/2021. A physical tour was conducted at 12:15 p.m., LPA observed the following:

Kitchen/ TV Room: All appliances were operative. LPA observed two (2) day perishable and seven (7) day non-perishable foods. Cleaning solutions are locked under the sink. At 12:22 p.m. Knives are kept locked in a kitchen drawer. TV room was clean and clear of clutter. Furniture appeared clean and in good repair. A fireplace located in the TV room is not in use.

Resident Rooms: There are four (4) bedrooms designated for resident use. All rooms were furnished with required lighting, dresser, chair, bed, and linens. There was an extra supply of linens in a hallway closet.

Bathrooms: Threre are two (2) bathrooms designated for resident use. Both bathrooms were clean, had grab bars and non slip rugs. A supply of hygiene products were observed in the bathrooms. Water temperature measured at 112.1 degrees Fahrenheit.

Living/dining area: Inside temperature was comfortable at 78 degrees Fahrenheit, with adequate lighting, living room and dining area were clean and clear of clutter. Living room and dining room furnisher appeared clean and in good repair.

Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. Side gate was closed but unlocked. There is a covered patio to provide shade and appropriate outdoor seating for residents. Smoke alarms and carbon monoxide detectors were tested and operating properly. Fire extinguisher was fully charged. Laundry area located before resident's room has detergents locked
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SERENITY VILLA ASSISTED LIVING
FACILITY NUMBER: 197609368
VISIT DATE: 11/09/2022
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Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. Side gate was closed but unlocked. There is a covered patio to provide shade and appropriate outdoor seating for residents. Smoke alarms and carbon monoxide detectors were tested and operating properly. Fire extinguisher was fully charged. Laundry has a washer and dryer that appear to be in good repair. Laundry detergent is kept located locked in cabinet above the washer and dryer.

Medications: LPA observed medication kept secure and locked in a hallways closet by the kitchen.

Resident Files: LPA reviewed resident files for four (4) out four ( 4) residents and could not find an updated physicians report for resident #1 (R1). LPA asked Licensee if R1's condition has changed since initial physicians report from October 2019 and appraisal/needs and services plan form March 2022. According to Licensee resident's health is declining but has not had an opportunity to updated reports.

Deficiency cited refer to 809D. Appeal right provided. Exit interview was conducted. Copy of the report was provided.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
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Document Has Been Signed on 11/09/2022 02:36 PM - It Cannot Be Edited


Created By: Evelin Rios On 11/09/2022 at 01:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SERENITY VILLA ASSISTED LIVING
FACILITY NUMBER: 197609368

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 4 residents' files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2022
Plan of Correction
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Licensee will submit to LPA an updated Physician's report and Appraisal/Needs and Services plan by POC date 11/18/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Eva Miller
LICENSING EVALUATOR NAME:Evelin Rios
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022


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