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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204856
Report Date: 08/12/2020
Date Signed: 08/14/2020 12:44:53 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 - IVFACILITY NUMBER:
198204856
ADMINISTRATOR:ARNIE ESPIRITUFACILITY TYPE:
740
ADDRESS:1036 VIA LA PAZTELEPHONE:
(310) 521-0043
CITY:SAN PEDROSTATE: CAZIP CODE:
90732
CAPACITY:6CENSUS: 5DATE:
08/12/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Renato Navarro Jr, ManagerTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Ana Soto initiated a case management visit. Due to the situation surrounding the Corona virus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted via a tele-visit with Renato Navarro, Jr., the facility manager.

LPA Soto conducted tele-visit interview with the manager and conducted a virtual visit of the entire facility. There were 2 staff members and 3 residents that were not wearing their masks. The residents and staff were practicing social distancing. LPA Soto advised manager that the residents must wear masks when they are around staff and other residents. The staff must wear their masks all the time during their work shift.

A telephonic exit interview was conducted with Renato Navarro, Jr. and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2020
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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