197609888-2-19-2025-31-AS-NRED-DE2UZS-20250219150200

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609888
Report Date: 02/19/2025
Date Signed: 02/19/2025 03:02:40 PM

Document Has Been Signed on 02/19/2025 03:02 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 MANOR LLC		FACILITY NUMBER:	197609888
ADMINISTRATOR/ DIRECTOR:	WEISMAN, MICHELLE		FACILITY TYPE:	740
ADDRESS:	4934 SWINTON AVE		TELEPHONE:	(818) 386-8540
CITY:	ENCINO	STATE: CA	ZIP CODE:	91436
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	02/19/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:30 AM
MET WITH:	Mo Naimuddin		TIME VISIT/ INSPECTION COMPLETED:	03:00 PM

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At approximately 10:30 a.m. on 02/19/2025, Licensing Program Analyst (LPAs) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and later the administrator and disclosed the reason for the visit.

A file review was conducted prior to today’s visit.

The facility was last visited on 12/27/2023 for an annual visit. It is a single story building with seven (07) bedrooms, five (05) bathrooms, kitchen, laundry room, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents, of which six (06) may be bedridden. Approved hospice waivers for six (06).

LPA observed a maintained front yard. A screening station at the front contained sanitizer and a visitor log. Postings at the front included COVID precautions, facility license, confidential complaints contacts, ombudsman contacts, neighborhood complaint procedures, theft and loss policy, rights of resident councils, and personal rights.

Walls, floors, windows, screens, and blinds were clean and in good repair. At 10:40 a.m. LPA measured the room temperature to be 71 degrees Fahrenheit. The living room contained a television, reading material, games, a piano, and furniture in good repair.

The facility has seven (07) bedrooms. One (01) bedroom is designated as a staff room. The staff room was unlocked and free of hazards. All bedrooms contained a chair, lamp, nightstand, storage, bed alarms, and a bed with adequate bedding. At approximately 11:00 a.m., three (03) beds were observed with bedrails attached but not in use. The administrator explained that bedrails are never used at night but only during the day to assist with grooming. All furnishings were clean and in good condition. All rooms had hospital beds with wheels in the locked position.

Naira Margaryan	TELEPHONE: (818) 596-4368
Nicholas Reed	TELEPHONE: (818) 669-8178
	DATE: 02/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025

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 MANOR LLC	FACILITY NUMBER: 197609888
	VISIT DATE: 02/19/2025

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The facility has five (05) bathrooms. Four (04) bathrooms are private and one (01) is shared. All bathrooms contained liquid soap, paper towels, trash can with a tight fitting lid, and grab bars near the toilet and shower or commodes with grab bars. At approximately 11:10 a.m. LPA measured the water temperature in the shared bathroom to be 108.2 degrees Fahrenheit.

LPA used the house telephone at 11:15 a.m. The phone was deemed operational. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen and garage. Appliances were in good condition. Sharps were locked under the island counter top.

The garage area was locked and contained a washing machine, a dryer, extra paper and incontinence supplies, medications, and chemicals. Both appliances were in working order. Detergents and cleaning supplies were locked near the appliances. LPA observed a shaded patio area in the rear of the facility. The patio contained furniture in good condition. A pool was gated, locked, and inaccessible.

Two (02) out of two (02) emergency exit paths were free from obstructions. Exit gates were unlocked with inward facing latches. Eight (08) out of eight (08) auditory alarms were turned on and functioning. Fire sprinklers were located throughout the facility. At 12:30 p.m., smoke and carbon monoxide detectors were tested and operational. Detectors were hard-wired and operated simultaneously. At approximately 12:35 p.m. LPA observed a fully charged fire extinguisher in the kitchen. It was purchased on 10/04/2024 with a receipt attached. At 12:45 p.m., LPA observed a complete first aid kit locked near the kitchen.

At 12:50 p.m. LPAs reviewed staff and resident files. All files were complete and available for audit.

During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health or safety hazards were observed.

Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025

LIC809 (FAS) - (06/04)

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