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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609888
Report Date: 12/15/2022
Date Signed: 12/15/2022 03:03:41 PM


Document Has Been Signed on 12/15/2022 03:03 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:SERENITY MANOR LLCFACILITY NUMBER:
197609888
ADMINISTRATOR:WEISMAN, MICHELLEFACILITY TYPE:
740
ADDRESS:4934 SWINTON AVETELEPHONE:
(818) 386-8540
CITY:ENCINOSTATE: CAZIP CODE:
91436
CAPACITY:6CENSUS: 6DATE:
12/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:29 PM
MET WITH:Janeth AlfaroTIME COMPLETED:
03:00 PM
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icensing Program Analyst (LPA) Abeye Duguma met with Janeth Alfaro for a One (1) Year Required - Infection Control visit for this facility. LPAs explained the reason for the visit.

A tour of the physical plant was conducted at 1:40 PM and the following was noted:

There are required posters posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. LPA were screened upon entry. All staff were observed to be wearing mask upon entrance and during visit.

The facility had submitted and approved Mitigation 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. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room.

The facility has 6 bedrooms and 5 bathrooms currently occupying 6 residents. The facility is fire cleared for 6 non-ambulatory residents, of which 6 may be bedridden. Hospice waiver for 6 residents.

(continued on LIC 809-C)
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022
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: SERENITY MANOR LLC
FACILITY NUMBER: 197609888
VISIT DATE: 12/15/2022
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Living and dining room furniture were also checked. The living room is neat and clean along with the dining room. The facility maintains a comfortable temperature at 79°F. The dual smoke and carbon monoxide detectors are hardwired and interconnected and observed to be operational. Fire extinguisher is located in the kitchen and observed to be full and last purchased on 02/01/2022. The facility is equipped with fire sprinklers.

The backyard of the facility has outdoor furniture, with a covered shaded area for clients. There is a swimming pool that is appropriately fenced and locked in the facility.

The garage is currently being partially used as a storage facility. Laundry room is also located in the garage. Laundry detergents, cleaning agents and other toxins are stored in a locked cabinet in the kitchen. Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents.

The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lit. Clients have a sufficient amount of personal hygiene product provided by the licensee.



Staff Room: Staff room was observed to be locked and located adjacent to the dining room. No medications were observed in the staff room.

The bathroom was checked for cleanliness and proper operations. LPA observed the appropriate grab bars in the toilet and shower. The hot water temperature was measured at a range of 118.4°F to 118.8°F. Towels and washcloths are not shared. There was enough clean linen available in stock at the cabinet.

Medications: LPAs observed medication cabinet to be locked and inaccessible to residents, located near the dining area. There is a complete first aid kit located inside the dining area.

Exit interview conducted. Copy of this report issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
LIC809 (FAS) - (06/04)
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