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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204489
Report Date: 10/21/2021
Date Signed: 10/22/2021 09:01:37 AM

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: 5DATE:
10/21/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Melanie TalladaTIME COMPLETED:
04:00 PM
NARRATIVE
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On 10/21/21, Licensee Program Analyst (LPA) Martessa Brown conducted an unannounced Health and Safety visit to the above facility. LPA met Melanie Tallada-Administrator and disclosed the purpose of today’s visit.

During todays visit LPA attempted to interview resident #1. Administrator stated resident was gone with office staff Yesenia Malagon. LPA verified from CDSS system that staff is not associated to the facility.

During today's visit the following deficiencies are being cited on the next page on LIC 809-D

During today’s visit LPA discussed the with the Administrator plan of corrections and due dates. Deficiencies cited on California code of regulations title 22, division 6, chapter 8.

An exit interview was conducted and a copy the report and the appeal rights were discussed and provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 III
FACILITY NUMBER: 198204489
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/22/2021
Section Cited

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Criminal Record Clearance:
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17...(1) Obtain a California clearance or a criminal record exemption as required by the Department..
(2) Request a transfer of a criminal record clearance as specified in Section 87355(c)
This requirement was not met as evidence by:
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Based on LPA's interview and records review staff Yesenia Malagon was not associated to the facility. LPA also cannot verify if staff is finger print cleared. Administrator doesn't have information.

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This poses and immediate health and safety risk to all residence at the facility.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2021
LIC809 (FAS) - (06/04)
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