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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204489
Report Date: 01/13/2022
Date Signed: 01/13/2022 10:20:14 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
MONTERY 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: 2DATE:
01/13/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:MELANIE TALLADATIME COMPLETED:
03:59 PM
NARRATIVE
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On 01/13/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted a case management visit in connection with the annual inspection visit. LPA met with administrator Melinda Tallada during the health and safety inspection visit.

During the health and safety inspection, LPA observed at 11:51 am several sharp knives inside the dishwasher and one sharp scissor in the kitchen drawer accessible to residents. At 12:31 pm water temperature in bathrooms tested at 149.0 degree F. LPA informed the administrator the facility violated Title 22. The licensee violated the California Code Regulations (CCR) Title 22, section 87303 (e)(2) and 87705(f)(1).

Deficiencies are issued and an exit interview is conducted with Melanie Tallada.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2022
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
MONTERY PARK, CA 91754

FACILITY NAME: SERENITY GUEST HOME III
FACILITY NUMBER: 198204489
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/14/2022
Section Cited

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87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
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This requirement was not met by evidence:

LPA tested the water temperature in both residents' bathrooms with a temperature of 149.0 degree F. This violation is an immediate health and safety risk to residents in care.
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Type A
01/14/2022
Section Cited

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87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
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his requirement was not met by evidence:

LPA observed sharp objects such as knives and scissors in the kitchen accessible to residents and not stored in locked drawers. This violation in immediate health and safety risks to residents in care.
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This violation was corrected during the visit 01/12/22.
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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2