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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610698
Report Date: 11/20/2024
Date Signed: 11/20/2024 10:53:32 AM

Document Has Been Signed on 11/20/2024 10:53 AM - 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:SERENITY SOURCE RESIDENTIALFACILITY NUMBER:
197610698
ADMINISTRATOR/
DIRECTOR:		REID, SHAWNICEFACILITY TYPE:
735
ADDRESS:19534 HART STREETTELEPHONE:
(310) 484-4184
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: 0DATE:
11/20/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Shawnice Reid, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:20 AM
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At 09: 00 AM, Licensing Program Analysts (LPAs), Huma Rahimi and Nadia Shahbazian conducted an announced Pre-Licensing visit to the above facility and met with Shawnice Reid, Licensee/Administrator, and explained the reason for the visit. At the time of this visit LPAs did not observe any clients present in the facility. Fire Clearance dated 11/04/2024 and received for six (6) Ambulatory. The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. The facility is a single-story building. Today's site visit consisted of LPAs touring the physical plant inside and outside and observed the following:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, oven, and a sink. Stove was observed in a good working condition. At 09:15 AM, LPAs observed adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). All knives and sharps are observed to be locked in a kitchen cabinet and inaccessible to clients. LPAs observed a Fire Extinguisher and was last purchased on 10/18/2024. It was observed handing on the wall in the kitchen by the dinning table.

MEDICATION ROOM: The centrally stored medication will be kept in the in the locked kitchen cabinet. Clients and staff files will be kept locked in the living room inaccessible to clients.



BEDROOMS: There are three (3) bedrooms designated for clients use. Bedroom number three (3) is shared. Bedroom number one (1) and two are private and the Licensee may change it to a shared bedrooms. All bedrooms are furnished with beds, dressers and required bedding and linen. The bedrooms have sufficient closet space and have sufficient lighting. Auditory alarms were tested and observed to be operational.
Continue on LIC 809C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SERENITY SOURCE RESIDENTIAL
FACILITY NUMBER: 197610698
VISIT DATE: 11/20/2024
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BATHROOMS: There is only one (1) bathroom at the facility. LPAs observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The water temperature was noted at 118.°.

LAUNDRY ROOM: The laundry room is located in the kitchen in a locked closet where all cleaning supplies and laundry detergents will be kept locked as well. The washer will be kept in the kitchen closet and the dryer will be kept in the garage of the facility. All cleaning supplies and laundry detergents are kept inaccessible to clients in care. The washer/dryer appear to be in good working condition.

COMMON AREAS: The facility maintains a comfortable temperature at 71°F. The living room and dining area
appeared clean and were properly furnished and has a television. No obstructions and or tripping hazards throughout the facility. LPAs observed a working telephone for the facility.

SURROUNDING GROUNDS: The facility has sufficient back yard space. LPAs did observe appropriate outdoor furniture in the backyard of the facility that can accommodate six (6) clients, LPAs observe a covered shaded area for clients with some games for outdoor activities. There is no swimming pool or any bodies of water at the facility. The exit was free of any obstruction or hazard.

Garage/Storage: The facility has an extra storage and LPAs observed locked and inaccessible to clients in care. LPAs observed a dryer in the garage.

SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. At 10:00 AM, they were tested and observed to be operational.

Component III was conducted with the Licensee/Administrator.



Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) and be notified by the CAB Analyst when your license has been approved.

Exit interview was conducted and with a copy of this report was provided to the Applicant/Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC809 (FAS) - (06/04)
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