198320198-5-4-2024-11-AS-RCLD-D4XT2Q-20240504142107

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320198
Report Date: 05/04/2024
Date Signed: 05/04/2024 02:21:23 PM

Document Has Been Signed on 05/04/2024 02:21 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	SERENITY ONE LLC		FACILITY NUMBER:	198320198
ADMINISTRATOR:	DAVID, JIMMY S.		FACILITY TYPE:	735
ADDRESS:	1559 WOODBURY DR.		TELEPHONE:	(424) 263-5067
CITY:	HARBOR CITY	STATE: CA	ZIP CODE:	90710
CAPACITY:	4	CENSUS: 4	DATE:	05/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:56 AM
MET WITH:	Co-Administrator Queenie David		TIME COMPLETED:	02:35 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 05/04/2024, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Co-Administrator Queenie David and Staff 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. LPA and staff 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 bathroom and measured at 117.9 F. A comfortable temperature was maintained in the facility. 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 and 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. Continue to LIC 809-C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2024

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 05/04/2024 02:21 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SERENITY ONE LLC	FACILITY NUMBER: 198320198
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80069(c)(1)

Client Medical Assessments

(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above for three out of four clients which poses a potential health risk to persons in care. LPA and staff did not observe TB results in C2, C3, and C4's binders.
	POC Due Date: 05/17/2024
	Plan of Correction
1 2 3 4	The Administrators will email TB results for C2, C3, and C4 to regina.cloyd@dss.ca.gov by the POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2024

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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SERENITY ONE LLC	FACILITY NUMBER: 198320198
	VISIT DATE: 05/04/2024

NARRATIVE

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Five (5) staff records were reviewed, 5 out of 5 staff records had required criminal record clearances or criminal record exemptions. Two staff members were interviewed.

Four (4) client records were reviewed and, 4 out of 4 client records had Admission Agreements, Medical Assessments, IPP and/or Needs & Services Plans. Two clients were interviewed. Two client medications were reviewed. LPA Cloyd reviewed P&I money, 4 out of 4 residents P&I were intact and were not commingled with facility funds or petty cash.

Deficiencies are being cited based on LPA's record review in accordance with the California Code of Regulations, Title 22, see LIC809D. During record review, LPA Cloyd and staff did not observe tuberculosis results for Clients #2, #3, and #4.

An exit interview was conducted, Plans of Corrections were developed and reviewed, and technical assistance was provided. A copy of this report and appeal rights were discussed and left with Queenie David.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2024

LIC809 (FAS) - (06/04)

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