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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609368
Report Date: 11/22/2024
Date Signed: 11/22/2024 03:15:57 PM

Document Has Been Signed on 11/22/2024 03:15 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/
DIRECTOR:		MARTINEZ, JERRILYNFACILITY TYPE:
740
ADDRESS:43126 FENNER AVETELEPHONE:
(661) 557-3434
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 2DATE:
11/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:Francisco Martinez/ LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On 11/22/2024 at 12:10 p.m., Licensing Program Analyst (LPA) Evelin Rios arrived to conduct an unannounced, annual inspection at the facility. Upon arrival, LPA met with staff #1 (S1), who granted access. S1 contacted the licensee, Francisco Martinez. The licensee met LPA shortly after and LPA explained the reason for the visit. The facility is a licensed Residential Care Facility for the Elderly (RCFE), with a capacity of six (6) non-ambulatory residents of which one (1) may be bedridden in bedroom #1. The facility also has a Hospice waiver for two (2) residents.

At approximately 12:20 p.m., LPA conducted a tour of the physical plant and the following was observed:

Common Areas: These included living room and dining area. The living room was clear of clutter, furnished with couches and recliners to sit the capacity of the facility. The dining room has a table with chairs large enough to seat six (6). A fireplace was observed secured with a screen. Furniture was observed to be in good repair. Hallways, entry and exits were clear of any obstructions.

Kitchen: The kitchen was observed to have a refrigerator, stove/oven, dishwasher and microwave. Fixtures and appliances were observed functional. LPA observed a sufficient amount of 2-days perishable and 7 -days non-perishable food in the facility. Knives were observed locked in a kitchen drawer. Centrally stored medication was observed locked in a closet by the kitchen. A fully charged fire extinguisher was observed by the kitchen. LPA observed a fully stocked first aid kit with the emergency and disaster plan.
Bedrooms: There are a total of four (4) resident bedrooms. LPA observed each resident room to be properly furnished and have appropriate beddings, linens and sufficient lighting. Exit doors had auditory alarms that were observed functioning.

(Continued on LIC809-C)
Eva MillerTELEPHONE: (818) 596-4373
Evelin RiosTELEPHONE: 424-299-6104
DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024
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 3
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: 11/22/2024
NARRATIVE
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Bathrooms: The facility has two (2) bathrooms one is located in a resident's private bedroom. Bathrooms were properly supplied with hand soap, toilet paper and paper towels. Hot water temperature in the bathrooms were tested at 12:00 p.m. and measured 111.8 degrees Fahrenheit, within regulation.

The facility is equipped with a carbon monoxide detector, LPA observed it functioning at 12:24 p.m. The facility is equipped with smoke detectors through out the facility. LPA observed licensee test smoke detectors at approximately 2:08 p.m. and were observed to be functioning.

Surrounding Grounds: Backyard space was large enough for outdoor activities. There is a covered patio with outdoor furniture.

Laundry Area: The laundry area was observed accessible to residents and leads to bedroom labeled #4 and the staff room. Cleaning supplies and detergents were locked in cabinets in the laundry room.

Client/Staff Records: Facility, resident and and staff records were reviewed to insure compliance. At 12:50 p.m. LPA reviewed two (2) of two (2) resident records and two (2) staff records. LPA's review of resident #1 (R1) record revealed a written pre-admission appraisal was not conducted prior to R2 moving in. LPA's review of one (1) of two (2) staff records revealed one (1) staff did not have 1st aid and CPR on file. LPA reviewed resident roster, personnel report, expired liability insurance certificate, infection control plan, emergency and disaster plans and drills.

LPA and licensee discussed the fire clearance request made on December 2022 to change the ambulatory status in bedroom #4. Licensee will send LPA an updated facility sketch. LIC200 is still on file for processing the request. LPA will also change current administrator Jerrilyn Martinez to Francisco Martinez.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were deficiencies observed during the visit refer to (LIC809-D). Exit Interview Conducted. A Copy of the report issued.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/22/2024 03:15 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in not renewing facilities liability insurance which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
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Licensee agreed to provide a copy of liability insurance renewal by POC due date.
Section Cited
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in staff not having active 1st aid and CPR certification on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Licensee agreed to provide a copy of certification by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Eva MillerTELEPHONE: (818) 596-4373
Evelin RiosTELEPHONE: 424-299-6104

DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024

LIC809 (FAS) - (06/04)
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