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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610698
Report Date: 01/07/2026
Date Signed: 01/07/2026 12:54:27 PM

Document Has Been Signed on 01/07/2026 12:54 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.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: 1DATE:
01/07/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Shawnice Reid, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
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At 09: 30 AM, Licensing Program Analyst (LPA), Huma Rahimi LPA conducted an unannounced annual inspection visit to the above facility. Upon arrival, LPA knocked on the door; however, no one answered. LPA contacted the Administrator, Shawince Reid, and explained the reason for the visit. The Administrator informed LPA that she would arrive at the facility in approximately three (3) hours and that there was no designee available to provide access, as the facility reportedly did not have any clients and was still awaiting a vendor number through North Los Angeles Regional Center (NLARC).

However, LPA observed a parked vehicle in front of the facility. When asked, the Administrator stated that the vehicle belonged to a family member who currently resides at the facility. LPA requested that the Administrator contact the family member to determine whether access could be granted for the inspection. The Administrator contacted the family member, who agreed to provide access.

LPA was greeted by Cathy Swint, who identified herself as a care provider (staff). Cathy informed LPA that the facility currently has one (1) client in care (Census: 1), placed through a third party agency, Free To Be Programs. The Administrator arrived at the facility at 12:30 PM.

Today's site visit consisted of LPA and staff touring the physical plant inside and outside. LPA observed the following:


Continue on LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 01/07/2026
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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 10:10 AM, LPA 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 the laundry closet which is located in the kitchen area and were inaccessible to a client in care. LPA observed a Fire Extinguisher and was last purchased on 1/07/2026. It was observed handing on the wall in the kitchen by the dinning table.

MEDICATION ROOM: The centrally stored medication are kept in the in the locked closet in the living room. Clients and staff files were observed to be locked in the living room.

BEDROOMS: There are three (3) bedrooms designated for clients use. All bedrooms are shared. 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.

BATHROOMS: There is only one (1) bathroom at the facility. LPA observed the bathroom is clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The water temperature was noted at 120.°.

LAUNDRY ROOM: The laundry room is located in the kitchen in a locked closet where all cleaning supplies and laundry detergents are locked as well. The washer is kept in the kitchen closet and the dryer is 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. LPA observed a working telephone for the facility.

SURROUNDING GROUNDS: The facility has sufficient back yard space. LPA did observe appropriate outdoor furniture in the backyard of the facility that can accommodate six (6) clients, LPA 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.
Continue on LIC 809C
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2026
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: 01/07/2026
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Garage/Storage: The facility has an extra storage and LPA observed locked and inaccessible to clients in care. LPA 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.

Between 10:45 AM to 11:55 AM, LPA reviewed records of one (1) client and one (1) staff. Records reviewed were updated and completed.

Administrative: LPA collected LIC500.

No deficiency observed and issued during today's visit. Exit interview conducted. Copy of this report signed and delivered.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2026
LIC809 (FAS) - (06/04)
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