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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608815
Report Date: 05/16/2022
Date Signed: 05/16/2022 12:34:42 PM

Document Has Been Signed on 05/16/2022 12:34 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:SERENE NATURE ASSISTED LIVINGFACILITY NUMBER:
197608815
ADMINISTRATOR:SAMUEL C. TANFACILITY TYPE:
740
ADDRESS:10987 LUDDINGTON STREETTELEPHONE:
(818) 253-5989
CITY:SUN VALLEYSTATE: CAZIP CODE:
91352
CAPACITY: 6CENSUS: 5DATE:
05/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jonathan Estrellado & Rima AbelianTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Tuesday Cabiness arrived at the facility to conduct an unannounced infection control inspection/visit. LPA was greeted at the front door by caregiver Jonathan Estrellado, who allowed LPA to enter. LPA’s temperature was immediately taken and documented; and LPA signed in the visitor book. LPA informed caregiver the reason of the visit. Caregiver contacted Administrator Rima Abelian, who also was informed the reason of the visit, and arrived shortly after during the inspection. The current census is (5). A hand sanitizing station, PPE supplies were at the front door. LPA observed COVID-19, CDC, Department of Public Health, and Licensing postings on the walls throughout the facility.

The infection control inspection began with the Administrator Rima, who escorting LPA throughout the facility. The facility has (6) bedrooms; with (2) shared room. (2) private, and (2) staff rooms. All beds were kept (6) feet apart, and properly furnished. COVID signs were also posted on residents' doors. The common areas were observed to be clean, including bathrooms, with soap and towels, and hand washing signs. LPA conducted a mitigation plan review with the Administrator, to obtain information on how the facility has implemented the plan. The Administrator reported to LPA, the facility has been COVID free since the pandemic, and will continue to implement the best practices for there facility. All (4) residents are vaccinated, and (1) that is not. All staff are vaccinated, and currently any new hires or new admits must have a negative COVID test or be vaccinated. No-one has received the booster as of yet. If they are not vaccinated, the facility will conduct weekly COVID testing. The facility keeps documentation of the test results and other pertinent information pertaining to COVID. Administration continue to conduct training to staff in relation to COVID-19. There is a paid sick leave policy in place. There are designated rooms for potential positive COVID residents. PPE, chemicals, cleaning supplies, emergency food and water, personal hygiene supplies, and paper products are stored at the facility. LPA observed a (30) day supply.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2022
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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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: SERENE NATURE ASSISTED LIVING
FACILITY NUMBER: 197608815
VISIT DATE: 05/16/2022
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LPA observed the facility has Licensing requirement for food supply. Currently, the facility has sufficient staff, and has a back up staff in place if needed. The facility has not had any positive COVID-19 reports for staff or residents. The facility is aware to report any changes with residents and staff to Licensing and there LPA, pertaining to positive COVID-19 cases.

Exit interview was conducted with Administrator and LPA updated contact information for the facility.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022
LIC809 (FAS) - (06/04)
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