197609702-4-21-2022-31-AS-NRED-CDPS3G-20220421133109

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609702
Report Date: 04/21/2022
Date Signed: 04/21/2022 01:32:51 PM

Document Has Been Signed on 04/21/2022 01:32 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	MY SERENITY SENIOR HOME		FACILITY NUMBER:	197609702
ADMINISTRATOR:	MASTOV, ELLA		FACILITY TYPE:	740
ADDRESS:	22414 HARTLAND ST		TELEPHONE:	(818) 992-7686
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	6	CENSUS: 6	DATE:	04/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Liliya Pyarali		TIME COMPLETED:	01:40 PM

NARRATIVE

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At 11:30 a.m. on 04/21/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and disclosed the reason for the visit. LPA and staff toured the facility inside and out.

The facility was last visited on 06/25/2021 for an annual inspection. It is a single story building with 5 bedrooms, 2 bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for 6 non-ambulatory residents, of which 1 may be bedridden in bedroom #5. The facility serves residents with dementia. Approved hospice waivers for 6.

Entry: LPA observed a maintained front yard. Entrance path was free from hazards. Signs regarding the facility’s visitation policy and masking requirement hung on the front door. Once inside, LPA observed postings for COVID precautions, ombudsman contact, confidential complaints, personal rights, and “Oxygen in use – No smoking”.

Screening: LPA was screened for infectious disease symptoms upon entry. The screening station contained surgical masks, gloves, gowns, digital thermometer, and a visitor log. The visitor log contained contact tracing information, symptoms, and temperature. LPA advised creating a column to track visitor vaccination status.

Bedrooms: The facility has 5 bedrooms. 4 bedrooms are designated for residents. Of the 4 resident bedrooms, 2 are private and 2 are shared. All bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. Beds in the shared bedrooms were at least 6 feet apart to accommodate physical distancing. All furnishings were clean and in good condition. Bedroom #3 and Bedroom #4 had ramps leading out. Ramps and handrails were sturdy and in good condition. Bedroom #2 is designated for staff. The staff room was unlocked and free from hazards.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MY SERENITY SENIOR HOME	FACILITY NUMBER: 197609702
	VISIT DATE: 04/21/2022

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Bathrooms: The facility has 2 bathrooms. Bedroom #3 had a private bathroom. A shared bathroom was located between Bedroom #5 and the staff room. All bathrooms contained liquid soap, paper towels, trash can with a tight fitting lid, grab bars in the shower and by the toilet, and a non-skid surface in the shower. A handwashing instruction sign was observed in the private bathroom but not the shared bathroom. At approximately 11:45 a.m. LPA measured the water temperature in Bathroom #1 to be 113.1 degrees Fahrenheit.

Kitchen: LPA observed an adequate supply of perishable and non-perishable food. Hazardous objects were locked. At approximately 12:00 p.m. residents gathered in the living room for lunch.

Laundry: LPA observed a washer and dryer in good condition near the kitchen. Detergent was inaccessible to residents and locked by magnet locks. Staff kept the keys in their possession.

Common Areas: Walls, floors, ceilings, windows, and blinds were clean and in good repair. A storage cabinet by the shared bathroom contained extra linens. At approximately 11:40 a.m. LPA measured the room temperature to be 73 degrees Fahrenheit.

Outdoor areas: A resident was observed sitting outside in a shaded patio area. All furniture was clean and in good repair. LPA also observed a basketball hoop, gas grill, and a locked garage.

Safety: All emergency exit paths were free from obstructions. Exit gates were unlocked. Emergency Disaster Plan was posted near the kitchen. Evacuation routes were illustrated and labeled. 2 out of 3 auditory devices were observed on and functioning. At approximately 11:45 a.m. LPA observed the auditory device in bedroom #5 to be off. Staff turned the device on immediately. A fire alarm is located near the front door. At 11:52 a.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last inspected on 05/21/2021. At 11:53 a.m. LPA tested the smoke and carbon monoxide detector to be operational. 3 other smoke detectors were hard-wired and heard functioning.

Pursuant to Title 22 of the CA Code of Regulations, 1 deficiency was cited on the attached LIC 809-D.

Exit interview conducted. Copy of report provided. Appeal rights provided. Citation issued.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/21/2022 01:32 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MY SERENITY SENIOR HOME	FACILITY NUMBER: 197609702
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(j)

87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 3 auditory devices which poses a potential Health, Safety or Personal Rights risk to persons in care.
	POC Due Date: 05/20/2022
	Plan of Correction
1 2 3 4	Staff turned the device on immediately during today's inspection. Licensee will submit a 5-day log for auditory device functionality to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022

LIC809 (FAS) - (06/04)

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