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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601630
Report Date: 08/07/2023
Date Signed: 08/07/2023 04:16:25 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/07/2023 04:16 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 SENIORS HOME IIFACILITY NUMBER:
198601630
ADMINISTRATOR:ANTOINETTE RICHARDSONFACILITY TYPE:
740
ADDRESS:13302 TOWNE AVETELEPHONE:
(310) 715-1280
CITY:LOS ANGELESSTATE: CAZIP CODE:
90061
CAPACITY:4CENSUS: 4DATE:
08/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:27 PM
MET WITH:Krystal HallTIME COMPLETED:
04:16 PM
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On 8/07/2023, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with Caregiver, Krystal Hall and the purpose of today’s visit was explained. Todays census is 4.

The facility is a single-story home located in a residential neighborhood. The facility consists of the following: three (3) resident bedrooms, one (1) resident bathrooms, dining area, kitchen, living room, laundry room, front and back yard, detached garage with shaded area.

LPA Shirley walked through all three (3) rooms. Bedrooms 1-3 are designated for the residents use. All bedrooms contained beds, nightstands, chairs, ample lighting and closet space.

LPA and Krystal Hall, Caregiver, toured the entire facility inside and out. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens and comforters 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 measured 112 F. There are no bodies of water or firearms on the premises.

A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough perishable and non-perishable food available which is stored properly. Medications are stored, locked and inaccessible to residents. Fire extinguishers were charged, smoke detectors and carbon Monoxide were operable. LPA checked first aid kit; and found that it was compliant with a manual. LPA also observed that the facility has a 30-day supply of Personal Protective Equipment (PPE). And all mandated posters were posted.



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.

Exit interview held and a copy of the report was provided to Staff, Krystal Hall.

SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa ShirleyTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2023
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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