565802325-3-29-2022-31-CR-EMHZ-CCYW48-20220329165708

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802325
Report Date: 03/29/2022
Date Signed: 03/29/2022 04:57:21 PM

Document Has Been Signed on 03/29/2022 04:57 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	KIDS TO KIDS - SERENITY HOUSE		FACILITY NUMBER:	565802325
ADMINISTRATOR:	DAVID YASUTAKE		FACILITY TYPE:	733
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	6	CENSUS: 0	DATE:	03/29/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Facility Administrator		TIME COMPLETED:	05:15 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 March 29, 2022, at 3:33pm Licensing Program Analysts (LPAs) Enrique Hernandez and Nancy O’Connell made an announced inspection to the Kids to Kids- Serenity House for the purpose of conducting Pre-Licensing inspection. LPAs met with applicant David Yasutake and facility representatives Madison Pennington Facility Manager (FM), Danny Bakst Head of Service (HS) who granted access to the facility. The entire physical plant was inspected. This is a three-bedroom, two-bathroom, single story family residence that includes a living room, dining area, kitchen, laundry area and a carport. There is no swimming pool or bodies of water on the premises. The home is currently vacant and there is no food in the home at the time of inspection. LPAs inspected the facility with the Licensee and observed the following: Bedroom #1: Is vacant, it has two twin sized beds, adequate closet and drawer space. Bedroom #2: Is vacant, it has two twin size beds, adequate closet and drawer space. Bedroom #3: Is vacant, it has two twin size beds, adequate closet and drawer space. Bathrooms: The home is equipped with three (2) Bathrooms. Bathroom one (1) is located next to bedroom #1 is equipped with one sink, shower and a toilet. Bathroom #2 is located adjacent to the master bedroom with one sink, a toilet bathtub and shower. All bathrooms were operable at time of inspection. LPA tested the hot water temperature during the time of the inspection the water temperature is 110 degree which meets the requirements. Living Room: There was an attached room space which will be utilized as game room/study room. There is a fireplace with the cover on. There was a rug and TV on the floor. There were a total of (3) fire extinguisher in the throughout the house. All smoke detectors and carbon monoxide detectors were tested and operable at time of inspection. Continue on LIC809-C

SUPERVISOR'S NAME: Kevin C Sauk	TELEPHONE: (310) -916-8922
LICENSING EVALUATOR NAME: Enrique M Hernandez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: KIDS TO KIDS - SERENITY HOUSE	FACILITY NUMBER: 565802325
	VISIT DATE: 03/29/2022

NARRATIVE

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Hallway: linen closet for extra storage.
The carport is detached to the home is where the facility van is kept and additional refrigerator is stored.
Kitchen: There was one (1) refrigerator, one (1) stove one (1) microwave and all appliances were operable at the time of the inspection.
Laundry room equipped with a sink, one (1) washer and one (1) dryer. The outdoor space is free of debris and any hazards.
Emergency disaster plan and personal rights are posted at the facility.
Cleaning solutions, disinfectants, and sharp knives were locked at the time of the inspection. An advisory was provided to obtain locked box for knives due to knives being stored in drawer with other non-cook ware items.
Area is designated for medication and will be locked and accessible only to employees supervising stored medications.

All smoke detectors and carbon monoxide detectors were tested and operable at the time of inspection. LPAs observed two fire extinguishers in the kitchen and around the home that were operable at the time of inspection. The first aid kits are fully stocked. The bathrooms were inspected and found to be clean. The facility has a working telephone. Licensee states that there is no weapons or guns on the premises. During the time of inspection, the facility vehicle wasn't at the facility and is being utilized by their other facility until clients are present in the current facility.
The home is clean, safe, sanitary, and in good repair.

LPA O'Connell received a copy of the CPR and First Aid certificate which was completed on 03/25/2022.

Applicant stated that he would:

Paint the interior of the facility, clean the vent grate in the main hallway
Obtain new shower head in bathroom #1
Clear out backyards weeds
Get rid of desk in dining room

Continue on LIC809-C

SUPERVISOR'S NAME: Kevin C Sauk	TELEPHONE: (310) -916-8922
LICENSING EVALUATOR NAME: Enrique M Hernandez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: KIDS TO KIDS - SERENITY HOUSE	FACILITY NUMBER: 565802325
	VISIT DATE: 03/29/2022

NARRATIVE

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Place work order for the following needs:

Missing cabinet drawer in closet for Level 4 bedroom
Secure cabinet doors to close tightly where chemicals are stored

Fire Clearance still pending.

The licensee was informed that once the Licensing Program Manager receives and reviews this report, then a provisional license will be granted.

Due to technical difficulties with the LPA's printer, a copy of this report will be emailed to the applicant.

SUPERVISOR'S NAME: Kevin C Sauk	TELEPHONE: (310) -916-8922
LICENSING EVALUATOR NAME: Enrique M Hernandez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

LIC809 (FAS) - (06/04)

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