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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603324
Report Date: 07/07/2023
Date Signed: 07/07/2023 03:26:38 PM

Document Has Been Signed on 07/07/2023 03:26 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SERENITY CARE GUEST HOMEFACILITY NUMBER:
198603324
ADMINISTRATOR:TAWFIK, GAMALFACILITY TYPE:
735
ADDRESS:7941 DEVENIR AVE.TELEPHONE:
(714) 351-4101
CITY:DOWNEYSTATE: CAZIP CODE:
90242
CAPACITY: 4CENSUS: 4DATE:
07/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:39 PM
MET WITH:Ramil Ortonio - CaregiverTIME COMPLETED:
03:40 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) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Ramil Ortonio (Caregiver), the reason for the visit was explained upon arrival. The facility is licensed to serve four (4) non-ambulatory clients. There is currently (1) non-ambulatory and (3) ambulatory clients serviced by South Central Los Angeles Regional Center at the facility.

The facility is a single-story home located in a residential area with four (4) bedrooms, two (2) full bathrooms, dining room, kitchen, living room, office area, and backyard shaded patio area with required furniture.



LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan.
Physical Plant & Environment Safety: There are 4 client bedrooms, 2 bathrooms, a living room, dining room, office area, kitchen, front yard, and backyard. Clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available and stored in restroom. The hot water temperature was tested in both bathrooms and measured between 108.3 and 110.8 degrees F which is within the required range of 105-120 degrees. All storage areas for cleaning solutions, toxins, knives, and hazardous items are stored in a locked cabinet and are inaccessible to clients. The last Fire/Emergency Drill was conducted on 04/3/23. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged.

(Continued on 809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2023
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SERENITY CARE GUEST HOME
FACILITY NUMBER: 198603324
VISIT DATE: 07/07/2023
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
Operational Requirements: There are currently 3 non-ambulatory and 1 ambulatory clients residing at the facility. There is an outdoor activity area that is shaded and furnished for outdoor use.
Staffing: There appears to be sufficient staffing at all times in the facility. Administrator Gamal F. Tawfik certificate expired on 5/11/2023, but there was proof showing that the renewal is pending and renewal was received back in February of this year.
Personnel Records-Training: Staff has criminal record clearance. Staff has current first aid and CPR. Staff files are maintained at the facility located in a locked cabinet. Staff have current CPR/first aid training and sufficient on-going training.
Client Rights-Information: The facility provides internet and telephone access for the clients in care.
Client Records-Incident Reports: Client files are kept in a locked cabinet and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Staff designated to administer medication has the proper annual training on file. Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers. During the visit today, LPA reviewed all 4 clients’ medication no issues were observed.
Incidental Medical & Dental: All medications for clients are stored in a locked cabinet and inaccessible to other clients.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
Emergency Intervention: Clients at this facility do not have restraints nor do they require the use de-escalation techniques.

LPA conducted 2 staff interviews and 3 resident interviews during today’s visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit.

Exit interview held and a copy of the report was provided to Caregiver Ramil Ortonio.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2