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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602281
Report Date: 11/10/2022
Date Signed: 11/10/2022 01:52:01 PM


Document Has Been Signed on 11/10/2022 01:52 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 IIIFACILITY NUMBER:
198602281
ADMINISTRATOR:ASTIER, MAYAFACILITY TYPE:
740
ADDRESS:212 S. ESSEY AVETELEPHONE:
(424) 338-6385
CITY:COMPTONSTATE: CAZIP CODE:
90221
CAPACITY:4CENSUS: 4DATE:
11/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:53 PM
MET WITH:Antoinette RichardsonTIME COMPLETED:
03:00 PM
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On 11/10/22, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Antoinette Richardson, administrator, and the purpose of today’s visit was explained. The facility is licensed to serve residents age range 60 and over. The facilities annual fees are past due and have an outstanding balance of $742.00, which was due on 10/13/22.

There are currently 4 South Central Los Angeles Regional Center clients in placement. The facility is a single-story structure located in a residential neighborhood. It consists of the following: living room, kitchen, dining room, two (2) resident bedrooms, two (2) bathrooms with a two-car detached garage and patio with chairs.

As part of the inspection, my primary focus was on infection control. LPA observed the facility’s infection control practices: LPA observed a sanitizing station at the facility entrance. PPE supplies are readily available to staff and residents, and additional supplies are stored. Sufficient paper, cleaning, and disinfecting supplies were observed. The facility has the mandated COVID infection control posters.

LPA and Ms. Richardson toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. 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, 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. A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit.

Continued on LIC 809-C
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022
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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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 SENIORS HOME III
FACILITY NUMBER: 198602281
VISIT DATE: 11/10/2022
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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. Both fire extinguishers were charged, smoke detectors and Carbon Monoxide were operable. Water temperature for the kitchen and bathrooms were complying.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations (Located in common areas and restrooms). LPA observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has a 90-day supply of Personal Protective Equipment (PPE).

LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing (www.cdss.ca.gov) Provider Informational Notices (PIN) for any updates relating to COVID-19 and other required guidance.



During today’s visit there were deficiencies observed and no citations issued.

Exit interview was held and a copy of the report were provided to Antoinette Richardson.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
LIC809 (FAS) - (06/04)
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