197609921-12-16-2021-31-AS-ADUA-C9S5VQ-20211216191754

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609921
Report Date: 12/16/2021
Date Signed: 12/16/2021 07:19:30 PM

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 SENIOR RETREAT		FACILITY NUMBER:	197609921
ADMINISTRATOR:	PERERA, JILSKA		FACILITY TYPE:	740
ADDRESS:	26213 BEECHER LANE		TELEPHONE:	(661) 313-3030
CITY:	STEVENSON RANCH	STATE: CA	ZIP CODE:	91381
CAPACITY:	6	CENSUS: 6	DATE:	12/16/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:56 AM
MET WITH:	Administrator		TIME COMPLETED:	01:02 PM

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	Licensing Program Analyst (LPA) Abeye Duguma met with the Administrator, Jilska Parera for a One (1) Year Required - Infection Control visit for this facility. LPA explained the reason for the visit. A tour of the physical plant was conducted at 10:00am and the following was noted: There is one entrance being utilized at the facility, 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 was screened upon entry. All staff were observed to be wearing masks upon entrance and during the visit. Signs to wear masks 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 outdoor visitors' area located in the backyard. The facility has sufficient stock of PPE in a cabinet near the dining area. The facility has a total of four (04) bedrooms, all utilized by residents and three (03) bathrooms for both residents and staff. The facility is fire cleared for one (01) bedridden and one (01) non-ambulatory in room #1, two (02) non-ambulatory in room #2, (01) non-ambulatory in room #3, one (01) ambulatory in room #4 and a hospice waiver for six (06). The facility is currently occupying five (05) residents of which four (04) arenon-ambulatory and under hospice care. The facility has outdoor furniture, with a covered shaded area for residents. The facility does not have a swimming pool/body of water. The garage is being used for storage. Laundry detergents, cleaning agents and other toxins are stored in a cabinet in the laundry room. Kitchen area was sufficiently stocked with at least 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. (continued on LIC 809-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021

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 SENIOR RETREAT	FACILITY NUMBER: 197609921
	VISIT DATE: 12/16/2021

NARRATIVE

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Knives and sharps are observed to be locked in a drawer inaccessible to residents. 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 74°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher is located in the kitchen nook, observed to be full and last purchased on 06/14/2021. The residents' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are well lit. Residents have enough personal hygiene product provided by the licensee and responsible parties. The bathrooms were checked for cleanliness and proper operations. The hot water temperature was measured at 118.8°F. Towels and washcloths are not shared. There was enough clean linen available in the master bedroom's walk-in closet. LPA observed medication and first aid kit to be locked and inaccessible to residents, located in a cabinet near the kitchen nook.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021

LIC809 (FAS) - (06/04)

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