<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320181
Report Date: 08/16/2023
Date Signed: 08/16/2023 09:25:33 PM


Document Has Been Signed on 08/16/2023 09:25 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:SERENITY VILLA JJA, INC.FACILITY NUMBER:
198320181
ADMINISTRATOR:ESPIRITU, JONATHANFACILITY TYPE:
740
ADDRESS:1036 VIA LA PAZTELEPHONE:
(310) 521-0043
CITY:SAN PEDROSTATE: CAZIP CODE:
90732
CAPACITY:6CENSUS: 0DATE:
08/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:49 PM
MET WITH:Jonathan Espiritu TIME COMPLETED:
03:59 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 08/16/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Jonathan Espiritu. LPA explained the purpose of today’s visit. The facility is licensed to operate for (6) ambulatory of which (2) may be non-ambulatory elderly adults ages 60 and above. The facility is approved for (2) hospice residents. Currently the home has no residents living in the facility.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (4) residents' rooms, (3) bathrooms, a living area, a dining area, a kitchen, an outside seating area, and a garage used for storage.

LPA toured the physical plant. There were no bodies of water on the premises. LPA identified a swimming pool behind a locked gate and not accessible to residents in care. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the resident's personal items was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 105.0 degrees F. A comfortable temperature of 81 degrees F. was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Two fire extinguishers were charged. The facility maintains a Medication Administration Record (MAR).

(Evaluation Report continues LIC 809-C)
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SERENITY VILLA JJA, INC.
FACILITY NUMBER: 198320181
VISIT DATE: 08/16/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed First Aid Kit was maintained. A working landline phone was operational. The facility maintains a record for monthly fire drills. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 06/09/23 through 06/09/24.

An audit of staff #1-#6 (S1-S6) personnel files revealed to be complete. Interviews were conducted with (3) (3) staff. The facility has the current administrator's certification on file for Evelyn Espiritu # 606355740 Expiration 08/21/24.

On 04/04/23 regional office received notification letter from administrator Jonathan Espiritu of Serenity Villa that a major water pipe busted in the bathroom #1 and that (6) residents were temporarily relocated. During the annual inspection visit, LPA observed both rooms were repaired and it is now in safe and healthful condition for residents.

No deficiencies during this inspection.

An exit interview was conducted with Jonathan Espiritu and a copy of the report was provided
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2