198602281-9-23-2024-11-AS-HENZ-D9DVC3-20240923161827

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602281
Report Date: 09/23/2024
Date Signed: 09/23/2024 04:18:38 PM

Document Has Been Signed on 09/23/2024 04:18 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	SERENITY SENIORS HOME III		FACILITY NUMBER:	198602281
ADMINISTRATOR:	ASTIER, MAYA		FACILITY TYPE:	740
ADDRESS:	212 S. ESSEY AVE		TELEPHONE:	(424) 338-6385
CITY:	COMPTON	STATE: CA	ZIP CODE:	90221
CAPACITY:	4	CENSUS: 4	DATE:	09/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:05 PM
MET WITH:	Administrator Maya Asteir & House Manager Maria Fausto		TIME COMPLETED:	04:45 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

On 09/23/2024 at around 2:00 pm Licensing Program Analyst (LPA) Hollie Enriquez conducted an unannounced annual required visit. LPA met with House Manager Maria Fausto and was later joined by Administrator Maya Astier and the purpose of today’s visit was explained. The facility is licensed to serve 4 non-ambulatory residents (one of which may be bedridden) with developmental disabilities ages 60 years and above. Currently, there are 4 residents in care, all of which receive services through the South Central Los Angeles Regional Center.

The facility is a single-story home located in a residential neighborhood consisting of the following: living room, kitchen, dining room/TV 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 firearms/ammunition on the premises.

All client rooms were checked. Beds and beddings were in good condition and storage for client personal belongings was observed. Walls and floors were in good repair. Perishable and non-perishable food supply was checked and met Title 22 regulations. Toxins, medications and knives were observed to be locked and inaccessible to clients. Bathrooms were found to be within Title 22 regulations and were clean and operational. Water temperature of both bathrooms were measured between 105.3-105.7 degrees Fahrenheit. A comfortable ambient temperature was maintained in the facility.

First aid kit was observed stocked and complete with manual. The required facility postings were observed and incompliance per Title 22.

Continued on 809C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Hollie Enriquez	TELEPHONE: (916) 908-8866
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SERENITY SENIORS HOME III	FACILITY NUMBER: 198602281
	VISIT DATE: 09/23/2024

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
26
27
28
29
30
31
32

During today’s visit there was a deficiency observed per Title 22, Division 6 Chapter 8 Article 08 and it is being cited on the LIC9099D. LPA observed about a 4 foot wide area in the backyard cement by the grassy area that had sunken and separated with large cracks and created uneven surface for walking. A plan of correction has been developed with Administrator Astier.

Due to time constraints the annual required visit will be continued at another unscheduled visit.

An exit interview has been conducted and a copy of this report and appeal rights were provided to House Manager Fausto.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Hollie Enriquez	TELEPHONE: (916) 908-8866
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 09/23/2024 04:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SERENITY SENIORS HOME III	FACILITY NUMBER: 198602281
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(d)(2)(4)

87307 Personal Accommodations and Services (d)The following space and safety provisions shall apply to all facilities:(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. (4)Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above as LPA observed about a four foot cement area (accesssible to clients) in the backyard with uneven broken cement, which poses a potential health, safety risk to persons in care.
	POC Due Date: 10/18/2024
	Plan of Correction
1 2 3 4	Administrator agrees to contact contractors to assess damage and obtain building permit as required in order to fully repair. Administrator agrees to develop a work plan to ensure construction has minimal impacts to clients in care. Administrator agrees to temporariliy block area so clients cannot access. Administrator will submit plan and proof of correction to: Hollie.Enriquez@dss.ca.gov

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Hollie Enriquez	TELEPHONE: (916) 908-8866
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3