198320540-2-13-2026-11-AS-WGIS-DR9RRB-20260213121452

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320540
Report Date: 02/13/2026
Date Signed: 02/13/2026 12:14:58 PM

Document Has Been Signed on 02/13/2026 12:14 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 FAMILY HOME CARE		FACILITY NUMBER:	198320540
ADMINISTRATOR/ DIRECTOR:	GARCIA, JASMIN		FACILITY TYPE:	740
ADDRESS:	2653 W 225TH STREET		TELEPHONE:	(310) 325-1735
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY: 6		CENSUS: 5	DATE:	02/13/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:57 AM
MET WITH:	Eusebio Huelar		TIME VISIT/ INSPECTION COMPLETED:	12:20 PM

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On 02/13/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Required -1 Year Annual Visit to the facility listed above. LPA met with Staff, Eusebio Huelar , and the purpose of today’s visit was explained. LPA was granted entry into the facility. The facility is licensed to serve six (6) non-ambulatory residents, two (2) of which maybe bedridden in room #5, and a Hospice Waiver for four (4).

Physical Plant/Structure The facility is a single-story structure in a residential neighborhood. The facility consists of five (5) bedrooms, three (3) bathrooms, living area, dining area, kitchen, outside shaded sitting area, and attached garage. LPA observed all walkways outside the facility were clean, clear, and free of hazards, debris, and obstructions. All ramps have secured handrails. LPA did not observe any bodies of water on the premises.

Bedrooms LPA inspected all bedrooms and observed them to be clean and in good repair. LPA observed the bedrooms have the required furniture that consists of a bed(s), dresser(s), nightstand(s) with lamps, chair(s), and ample storage space for personal belongings. LPA observed the beds have the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. LPA observed an ample supply of linens were observed in a closet in the hallway.

Bathrooms LPA inspected the bathrooms and observed they were operational. LPA observed safety handrails secured to the wall. LPA observed an ample supply of hygiene products. LPA observed an ample supply of towels and wash clothes. The water temperatures measured 111.3-degrees, 110.2-degrees, and 112.1-degrees Fahrenheit.

Kitchen LPA observed the kitchen clean and sanitary. LPA observed all appliances are operational and in good repair. LPA observed an ample supply of dishware, cookware, and cutlery. LPA observed a 3-day

NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/13/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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 FAMILY HOME CARE	FACILITY NUMBER: 198320540
	VISIT DATE: 02/13/2026

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supply of perishable foods and a 7-day supply of non-perishable foods properly stored, labeled, and dated. The water temperature measured 110.6-degrees Fahrenheit. LPA observed sharps and knives secured in a locked drawer in the kitchen and are inaccessible to residents. LPA observed cleaning supplies and toxins secured in the locked cabinet under the kitchen sink and are inaccessible to residents.
Common Areas LPA observed the facility appropriately furnished during time of visit. LPA observed in the living room has two (2) recliners, three (3) couches, and two (2) chairs available for resident use. LPA observed games and activities available for residents. The dining room has a large table with chairs to accommodate all residents. LPA observed that all walkways and hallways inside the facility are clean, clear, and free of obstruction and hazards. The facility was maintained at a comfortable temperature.
Files LPA reviewed the files for five (5) residents. LPA observed resident’s files have the required documents. LPA reviewed the files for the Administrator and three (3) staff and observed they have the required documents, clearance, certification, and training. LPA observed the administrator’s Administrator Certificate #6070589740 is valid till 06/09/2026. LPA observed required documents posted throughout the facility. LPA received and reviewed a copy of the facility’s liability insurance through Acord that is valid till 10/11/2026. LPA observed the facility’s Licensing Fees are current.
Medications LPA observed all Centrally Stored Medications secured in a locked cabinet in the dining area. LPA observed all medications in their original packaging. LPA reviewed the medication and Medications Administration Record (MAR), for five (5) Residents and observed they are consistent with properly documented records.
Safety LPA observed smoke and carbon monoxide detectors are operable. The last Emergency Drill was conducted on 01/01/2026. LPA observed two (2) fully charged fire extinguishers last serviced on 06/26/2025. LPA received and reviewed the Emergency and Disaster Plan for Residential Care Facilities for the Elderly. All exits are indicated with an EXIT sign. The facility has a working landline telephone. LPA inspected the First Aid Kit and observed it has the required items and a current manual.
Infection Control LPA observed required Infection Control signs posted throughout the facility. Upon entry, LPA observed a sanitizing station that has Visitor Sign-In Logs, hand sanitizer, masks, and gloves available. LPA observed a 30-day supply of Personal Protective Equipment (PPE). LPA observed an ample supply of cleaning supplies.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies therefore NO citations were issued at this time.

An exit interview was conducted with Staff, Eusebio Huelar, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/13/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2026

LIC809 (FAS) - (06/04)

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