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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204489
Report Date: 03/11/2022
Date Signed: 03/11/2022 03:47:38 PM


Document Has Been Signed on 03/11/2022 03:47 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
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: 0DATE:
03/11/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Felicidad Isor, Care giverTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ana Soto conducted a case management visit. Today’s case management visit was conducted with Felicidad Ison, Care giver.

LPA Soto arrived at facility to deliver amended findings for previous complaints. When LPA Soto entered the home care giver advised LPA Soto that all the residents had been moved out over a month ago. The facility was going to begin updating the facility floors. LPA Soto toured the facility all residents not at facility, their belongings also moved with the residents. All the bedrooms were empty, just had mandated furnisher. LPA Soto spoke with administrator Melanie Tallada via telephone. She informed LPA Soto that the residents had been moved to another facility they operate also. The facility has not began any remodeling of the floors. Administrator failed to report it to LPA and CCLD. LPA issued a citation.

An exit interview conducted with Felicidad Isor, Care giver, a hard copy of report provided along with Appeal rights.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022
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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Document Has Been Signed on 03/11/2022 03:47 PM - It Cannot Be Edited

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: 03/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/20/2022
Section Cited

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87211(a)(1)(A-D) - Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below....
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This was not met as evidence by: Based on observations and interviews the facility failed to report the transferring of resident to a new facility. which potentially psoes a health and safety risk for the persons in care.
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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: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022
LIC809 (FAS) - (06/04)
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