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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320198
Report Date: 08/26/2021
Date Signed: 08/26/2021 01:00:18 PM

Document Has Been Signed on 08/26/2021 01:00 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 ONE LLCFACILITY NUMBER:
198320198
ADMINISTRATOR:DAVID, JIMMY S.FACILITY TYPE:
735
ADDRESS:1559 WOODBURY DR.TELEPHONE:
(310) 801-4379
CITY:HARBOR CITYSTATE: CAZIP CODE:
90710
CAPACITY: 4CENSUS: 0DATE:
08/26/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Jimmy S David, LicenseeTIME COMPLETED:
12:30 PM
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Licensing Program Analysts (LPA) Ana Soto, conducted a announced visit to the facility for the purpose of a
Pre-Licensing evaluation. An application was submitted to Community Care Licensing Department (CCLD) on
05/15/2021 for an initial license for an Adult Residential Facility to serve Adults for ages 18 - 59 years. The requested capacity is for (4) Clients, 4 - ambulatory and 0 - Non-ambulatory. Today's pre-licensing visit was conducted with Jimmy S. David, the facility Licensee.

An application was submitted to Community Care Licensing Department (CCLD) on 05/15/2021 for an initial
license for an Adult Residential Facility to serve Developmentally Disabled Adults for ages 18-59 years. The
requested capacity is for (4) clients, 4 ambulatory, 0 non-ambulatory. Structure : Facility is a five (5)
bedrooms, and two (2) full bathrooms, single story house with front porch, attached 2 car garage, back yard. The facility is a beige stucco structure with a brick gate leading to front porch, front yard landscape is in good condition. Back yard has shaded area. Signal System : No signal system in facility. Bedroom Residents : There shall be no more than two clients per bedrooms. The bedrooms are designated client bedrooms properly equipped with regulation guidelines of 1 bed, 1 chair, 1 night stand, 1 lamp and overhead lighting. The 4 bedrooms will private bedrooms for 1 client per bedroom. Bedroom 5 will be converted to an office. Staff :No bedrooms will be used for awake staff. Bathrooms: 1 full bathroom near bedrooms and 2nd bathroom in room #4. The 2 bathrooms have a working toilet and wash basin and a walk-in shower and/or tub. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2021
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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