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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204489
Report Date: 09/27/2021
Date Signed: 09/27/2021 02:40:07 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:SERENITY GUEST HOME IIIFACILITY NUMBER:
198204489
ADMINISTRATOR:LOLITA ESPIRITUFACILITY TYPE:
740
ADDRESS:1080 VIA LA PAZTELEPHONE:
(310) 548-1700
CITY:SAN PEDROSTATE: CAZIP CODE:
90732
CAPACITY:6CENSUS: 6DATE:
09/27/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Hazel Magalona, House ManagerTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) conducted an unannounced case management Health check visit. LPA Ana Soto was met by Hazel Magalona, House Manger and the purpose of the visit was explained.

LPA Soto and Hazel toured the entire facility, interviewed resident's #1-#6 and Staff #1 & #2. R#1 & R#2, complained of medical issues. R#1 & R#2, both resident have seen doctor and have been given treatment and medication. R#3 -R#6 where doing well and staff were treating them good.

An exit interview was conducted with Hazel Magalona, House Manager, and a hard copy was provided.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021
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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