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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609807
Report Date: 08/03/2024
Date Signed: 08/03/2024 04:02:08 PM

Document Has Been Signed on 08/03/2024 04:02 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:SERENITY PATHWAYS, INCFACILITY NUMBER:
197609807
ADMINISTRATOR/
DIRECTOR:		ISIKO, FAITH NASSALIFACILITY TYPE:
735
ADDRESS:10522 CEDROS AVETELEPHONE:
(818) 274-2692
CITY:MISSION HILLSSTATE: CAZIP CODE:
91345
CAPACITY: 4CENSUS: 3DATE:
08/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Kumbirai "Peter" Zvatta - AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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A Required One (1) year visit was conducted today by Licensing Program Analyst (LPA) Gary Tan. LPA met with Kumbirai Zvatta (Peter), alternate Administrator and purpose of the visit stated. LPA observed that the two (2) residents were at the facility during visit and the other was picked up by family. This facility is a North Los Angeles Regional Center (NLARC) vendored facility Level III.

A tour of the physical plant was conducted at 12:24 PM and the following was noted:

The front main door is the only entrance being utilized at the facility. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted approved Mitigation and Infection Plan.

Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing, and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with cover.

The facility has a designated visitors' area at the backyard and the office converted garage. The facility has sufficient stock of PPE in the garage.

The facility is a single storey house and has four (4) bedrooms and two (2) bathrooms. One (1) bedroom and one (1) bathroom is designated for staff use. There is no body water in the facility. The facility is fire cleared for four (4) ambulatory residents.

(continued to LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2024
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SERENITY PATHWAYS, INC
FACILITY NUMBER: 197609807
VISIT DATE: 08/03/2024
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(continued from LIC 809)

Bedrooms were toured and observed to be clean and properly furnished. Linen storage was also checked and observed to have ample supply of clean linen and towels.
Bathrooms were observed to be clean and sanitary with necessary supplies. Hot water temperature was measured at 115.7°F and within the required range.
Physical plant was checked for cleanliness and condition. Facility was in good repair and observed to be clean and free of clutter during today's visit.
Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition.
Kitchen area was observed to be clean and sanitary and free of pests. Food. The facility is observed to have sufficient food supply for the clients both perishable and non-perishable. Laundry area is located adjacent to the kitchen. Knives and sharps are observed to be locked in the kitchen drawer. All toxins, cleaning agents and laundry soap are locked in the laundry area cabinet.
Fire extinguisher - There is a fire extinguisher located near the dining area. Extinguisher was observed to be operable and last inspected on 04/11/24. Dual smoke and carbon monoxide alarms were hardwired and inter- connected, tested and observed to be operational. Temperature of facility wall thermostat was set at 75°F and observed to be within the required range. Garage is attached to the house but has no access from the inside. Garage is also being used as an office and meeting area, frozen foods, and other supplies storage.

Medication was observed to be inaccessible and stored in a secured medication cabinet in the kitchen. There is a complete First Aid kit inside the medication cabinet.



Staff records were reviewed and appeared to be complete and updated. Clients’ records are also reviewed and appeared to be complete and updated.

Disaster drill was last conducted on 07/25/24. Required posting observed in facility (complaint hot line poster, personal rights, etc.).

There was no immediate health and safety hazard observed during the day of inspection. Exit interview conducted and a copy of this report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2024
LIC809 (FAS) - (06/04)
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