197609921-1-27-2025-31-AS-TCAS-DDBS8N-20250127123926

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609921
Report Date: 01/27/2025
Date Signed: 01/27/2025 12:39:38 PM

Document Has Been Signed on 01/27/2025 12:39 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 SENIOR RETREAT		FACILITY NUMBER:	197609921
ADMINISTRATOR/ DIRECTOR:	PERERA, JILSKA		FACILITY TYPE:	740
ADDRESS:	26213 BEECHER LANE		TELEPHONE:	(661) 313-3030
CITY:	STEVENSON RANCH	STATE: CA	ZIP CODE:	91381
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	01/27/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Glenda and Desiree Dulay		TIME VISIT/ INSPECTION COMPLETED:	01:00 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) Tuesday Cabiness conducted an unannounced visit, for the facility's one year required annual inspection. LPA was greeted by caregiver Glenda and Desiree Dulay, who allowed LPA to enter. LPA explained the reason for the visit and contacted Co-Administrator Errol Fernando. The annual inspection included: Common Areas: Living/dining/family room furniture were checked. The living room is neat and clean. The facility maintains a comfortable temperature at 75°F. The smoke detectors are hardwired and interconnected and observed to be operational. There is a carbon monoxide installed at the facility. Fire extinguisher is located in the dining area and observed to be full and charged. The living room was clear of clutter, furnished with couches and recliners to sit the capacity of the facility. Furniture was observed to be in good repair. Hallways, entry and exits were clear of any obstructions. Kitchen: The kitchen was observed to have a refrigerator, stove/oven, dishwasher and microwave. Fixtures and appliances were observed functional. LPA observed a sufficient amount of 2-days perishable and 7 -days non-perishable food in the facility. Knives were observed locked in a kitchen drawer. Centrally stored medication was observed locked in a cabinet by the kitchen. There is an extra fridge in the garage, stocked with food. Bedrooms: There are a total of four (4) resident bedrooms. LPA observed each resident room to be properly furnished and have appropriate beddings, linens and sufficient lighting. Exit doors had auditory alarms that were observed functioning. The backyard of the facility has outdoor furniture, with a covered shaded area for clients. There is no body of water in the facility. There are (2) exit gates that were easily accessible. Passageways were clean and unobstructed.

Troy Agard	TELEPHONE: (818) -596-4334
Tuesday Cabiness	TELEPHONE: (818) 299-4975
	DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

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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Document Has Been Signed on 01/27/2025 12:39 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SERENITY SENIOR RETREAT	FACILITY NUMBER: 197609921
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

HSC

1569.69(a)

Other Provisions

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on staff record review, the licensee did not comply with the section cited above in [2] out of [2] staff files, LPA did not observe medication training records for both staff. Which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/10/2025
	Plan of Correction
1 2 3 4

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.

Troy Agard	TELEPHONE: (818) -596-4334
Tuesday Cabiness	TELEPHONE: (818) 299-4975
	DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

LIC809 (FAS) - (06/04)

Page: 2 of 3

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 SENIOR RETREAT	FACILITY NUMBER: 197609921
	VISIT DATE: 01/27/2025

NARRATIVE

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The garage is attached to the house. The garage is currently being used as rest area and storage for old equipment, chemicals, and supplies. Laundry room attached to the garage where LPA observed laundry detergents, cleaning agents and other toxins are stored in a locked cabinet in the laundry area. The laundry room was observed to be locked during visit.

The bathroom was checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the toilet and shower area. The hot water temperature was measured at 113.7°F. Towels and washcloths are not shared. LPA observed non-skid mats and shower chairs.

Medications: LPA observed medication in the dining area cabinet to be locked and inaccessible to residents. There were two (2) complete first aid kits with manual observed.

Client records: Client records were reviewed. Residents record appeared to be complete and current.
Staff records: LPA conducted a complete file review of staff records. Staff records appeared to be complete and updated, except yearly and medication training could not be verified. LPA was told they would email documentation. Technical assistance violations and citation were issued.

Disaster drill was last conducted on 01/11/2025.

Citation and technical violations issued, appeals rights, exit interview conducted, and copy of this report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

LIC809 (FAS) - (06/04)

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