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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320198
Report Date: 10/03/2022
Date Signed: 10/03/2022 03:45:11 PM

Document Has Been Signed on 10/03/2022 03:45 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 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: 2DATE:
10/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Lead Cargiver - Melissa Desagun/Licenseee Jimmy David on phoneTIME COMPLETED:
03:15 PM
NARRATIVE
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On 10/03/2022, Licensing Program Analyst (LPA) Don Senaha and LPA Mario Leon conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPAs met with Lead caregiver Melissa Desagun and Licensee Jimmy David via phone and explained the purpose of today’s visit. The facility is licensed to operate for four (4) developmentally disabled clients of between the ages of 18 through 59 of which three (3) can be non-ambulatory clients.


The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) client rooms, one (1) office space, two (2) bathrooms with one (1) of those bathrooms being in the master room, a living area, a dining area and kitchen. There is an outside covered patio area with ample seating. The laundry area is in the garage. The garage is attached with access from the front of the garage and a side door directly outside the front door. Garage includes the washer and dryer for washing clothes.


LPAs and caregiver Melissa toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature met Title 22 standards in the bathrooms and kitchen sink and measured between 109.0 F and 112,8 F. A comfortable temperature was maintained in the facility.


Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2022
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 10/03/2022 03:45 PM - It Cannot Be Edited


Created By: Don Senaha On 10/03/2022 at 02:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SERENITY ONE LLC
FACILITY NUMBER: 198320198

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPAs observed cleaning solutions under the sink unlocked, two cans of paint on the side of the house and hardwood toxins in the patio area unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2022
Plan of Correction
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Licensee immediately removed the cleaning solutions, two cans of paint and the hardwood toxins and locked them in a secure area that clients are not able to access.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Ulysses Coronel
LICENSING EVALUATOR NAME:Don Senaha
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2022


LIC809 (FAS) - (06/04)
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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 ONE LLC
FACILITY NUMBER: 198320198
VISIT DATE: 10/03/2022
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LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. There is one (1) fire extinguisher fully charge located in the living room area. Smoke detectors and carbon monoxide were operable and in working condition. A reviewed of Medication Records Administration (MAR) was observed to be maintained in order and accurate.

During the visit, LPA observed the facility infection control practices. LPA observed hand sanitizer available and temperature taken upon entry to the facility. There is a fully stocked first aid kit in the office room.

One deficiency was cited during this inspection visit. See 9099D page.

There were three (3) technical advisories given. See TA 9102 pages.

An exit interview was conducted and a copy of this report was provided to DSP Queenie David.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2022
LIC809 (FAS) - (06/04)
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