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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601451
Report Date: 08/16/2022
Date Signed: 09/09/2022 04:33:32 PM

Document Has Been Signed on 09/09/2022 04:33 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 RESIDENTIAL CAREFACILITY NUMBER:
198601451
ADMINISTRATOR:NICOLE BRISCOEFACILITY TYPE:
735
ADDRESS:9810 S. HARVARD BLVDTELEPHONE:
(310) 765-0130
CITY:LOS ANGELESSTATE: CAZIP CODE:
90047
CAPACITY: 4CENSUS: 3DATE:
08/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Quinston ArchieTIME COMPLETED:
02:30 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
Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced required 1- year visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA Bunker was properly screened for COVID-19 symptoms and temperature was checked. LPA Bunker met with staff Quinston Archie and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved mitigation plan report. There are currently three (3) South Central Los Angeles Regional Center (SCLARC) consumers in placement. The facility's annual fees are current.

The following Domain will be observed and reviewed: Infection Control Practices "I will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections."

The facility is a single-family home located in a residential neighborhood. Staff Quinston Archie and LPA Bunker toured the facility which consisted of the following: Living room, dining room, kitchen, bedrooms, 1 1/2 bathroom, laundry room, shaded area, indoor/outdoor activity areas, and a detached garage. The front and back yard landscape is in good condition at the time of the visit.

Due to time constraints, LPA Bunker will return at a later date to complete the visit.
There were no deficiencies cited. Exit interview conducted.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2022
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 1