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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602281
Report Date: 10/04/2023
Date Signed: 10/05/2023 08:23:44 AM


Document Has Been Signed on 10/05/2023 08:23 AM - 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 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:
10/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator DeAnthony HardimanTIME COMPLETED:
02:52 PM
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On 10/04/23, Licensing Program Analyst (LPA) Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator DeAnthony Hardiman as the purpose of today’s visit was explained. The facility is licensed to serve 4 non-ambulatory of which 1 may be bedridden developmentally disabled clients (age 60 and over). Clients are linked with the South Central Los Angeles Regional Center.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: living room, kitchen, dining room, two (2) client bedrooms, one (1) furnished bedroom for isolation if needed, two (2) bathrooms of which (1) is private, a two-car detached garage that is used for storage and houses a washer and dryer, and a shaded patio area. 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. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Toxins and knifes were observed to be locked and inaccessible to clients. Bathrooms were found to be within Title 22 regulations and were clean and operational. A comfortable temperature is maintained in the facility.



LPA conducted a records review of 2 staff records, 2 client records, and 2 Medication Administration Records, No discrepancies observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire drill was conducted on 07/06/23, (2) fire extinguishers fully charged, carbon monoxide detectors and smoke detectors are operational. Landline and internet service was observed. Liability insurance is active.

Exits/ Walkways around the facility were free of debris and hazards. During today’s visit no discrepancies were cited. Exit interview conducted with Administrator DeAnthony Hardiman, and a copy of this report was provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023
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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