<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609368
Report Date: 03/11/2025
Date Signed: 03/11/2025 10:46:29 AM

Document Has Been Signed on 03/11/2025 10:46 AM - 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, FRANCISCOFACILITY TYPE:
740
ADDRESS:43126 FENNER AVETELEPHONE:
(661) 557-3434
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: DATE:
03/11/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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 03/11/2025 in conjunction to complaint control #31-AS-20250124110820, Licensing Program Analyst (LPA) Evelin Rios conducted a Case Management Deficiencies Visit. LPA met with the administrator and explained the reason for the visit.

On 01/28/2025 at 10:24 a.m., LPA conducted a physical plant tour to ensure the health and safety of the residents in care. During this tour, at approximately 10:27 a.m., LPA interviewed resident #1 (R1). At approximately 10:30 a.m., LPA conducted an interview with the administrator. At 11:00 a.m., LPA reviewed the facility's Licensing Information System (LIC) facility profile, Guardian Background Check System, employee roster, and fire inspection with facility sketch. LPA's review of the approved fire inspection (LIC 850) from 10/12/17 and facility sketch revealed the facility has a capacity of six (6) with five (5) non ambulatory residents and one (1) bedridden resident. Facility sketch revealed bedroom labeled #1 is approved as a shared room for one (1) bedridden resident and one (1) non ambulatory resident, bedroom labeled #2 is approved for two (2) non ambulatory residents and bedroom labeled #3 and #4 are cleared for one non ambulatory resident each. During the physical plant tour LPA observed the garage had been converted into living quarters for the licensee and bedrooms labeled #2 and #3 are each currently occupied by licensee's family members. The Administrator stated that they intend to comply with regulations and will be submitting the required documentation.

Deficiency cited refer to (LIC809-D). Exit interview conducted. Appeals rights provided. Copy of report provided.
Eva MillerTELEPHONE: (818) 596-4373
Evelin RiosTELEPHONE: 424-299-6104
DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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
Document Has Been Signed on 03/11/2025 10:46 AM - 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: 03/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/11/2025
Section Cited
CCR
87208(a)(7)(A)

1
2
3
4
5
6
7
(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility...The plan and related materials shall contain the following: (7) Sketches, showing dimensions, of the following (A) Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended and a designation of the rooms...This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee agreed to provide a copy of the approved permit for the garage conversion and submit an updated facility sketch with current designation of the rooms by POC due date.
8
9
10
11
12
13
14
Based on interviews and record review, the licensee did not comply with the section cited above in not providing CCLD with an updated facility sketch and designation of the rooms which is a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025

LIC809 (FAS) - (06/04)
Page: 2 of 2