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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603324
Report Date: 08/04/2025
Date Signed: 08/04/2025 12:21:51 PM

Document Has Been Signed on 08/04/2025 12:21 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SERENITY CARE GUEST HOMEFACILITY NUMBER:
198603324
ADMINISTRATOR/
DIRECTOR:		TAWFIK, GAMALFACILITY TYPE:
735
ADDRESS:7941 DEVENIR AVE.TELEPHONE:
(714) 351-4101
CITY:DOWNEYSTATE: CAZIP CODE:
90242
CAPACITY: 4CENSUS: 4DATE:
08/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Jeffren Mungcal, StaffTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced required annual visit. LPA was greeted by Frederick (Erick) Violago, staff and the purpose of the visit was explained. Jeffren Mungcal, staff and Designated Responsible party in Administrator’s absence, arrived shortly after.

The facility is licensed for four (4) clients age range 18 through 59, approved for non-ambulatory in rooms 1, 2 and 4 only and are operating within the scope of their license. The facility is vendorized with South Central Los Angeles Regional Center.

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

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

LPA and licensee toured 4 client bedrooms, 2 bathrooms, a living room, dining room, office area, kitchen, front yard, and backyard. Clients’ bedrooms were checked and were observed to have sufficient lighting and the required furniture with clean linens. Hygiene products are readily available and stored in restroom and a linen closet in the hallway. The hot water temperature was tested in both bathrooms and measured 116.4 degrees F in bathroom #1 and 114.9 degrees F in bathroom #2, which is within the required range of 105-120 degrees.

continued on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2025
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
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SERENITY CARE GUEST HOME
FACILITY NUMBER: 198603324
VISIT DATE: 08/04/2025
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 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 07/06/2025. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. The kitchen was observed clean and free of debris and pests. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. There is a fireplace with a covered glass-door screen in the dining room. The dining room and living room are clean and have sufficient seating for clients in care.

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.

The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.

Clients at this facility do not have restraints nor do they require the use of de-escalation techniques. The facility provides internet and telephone access for the clients in care.

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.

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. 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.

All medications for clients are stored in a locked cabinet and inaccessible to other clients.

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 licensee.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2025
LIC809 (FAS) - (06/04)
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