197609888-2-22-2026-31-AS-TSMH-DRJRTZ-20260222121910

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609888
Report Date: 02/22/2026
Date Signed: 02/22/2026 12:19:34 PM

Document Has Been Signed on 02/22/2026 12:19 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:	SERENITY MANOR LLC		FACILITY NUMBER:	197609888
ADMINISTRATOR/ DIRECTOR:	MO NAIMUDDIN		FACILITY TYPE:	740
ADDRESS:	4934 SWINTON AVE		TELEPHONE:	(818) 386-8540
CITY:	ENCINO	STATE: CA	ZIP CODE:	91436
CAPACITY: 6		CENSUS: 6	DATE:	02/22/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:35 AM
MET WITH:			TIME VISIT/ INSPECTION COMPLETED:	12:32 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), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility. LPA was greeted by staff and disclosed the purpose of the visit. The administrator was not present and staff contacted licensee and designee arrived later. LPA conducted a tour of the physical plant at approximately 8:40 am to ensure there are no health and safety hazards, and facility is in compliance with Title 22 Regulations. Common areas were observed for the ability to safely serve the needs of the residents. These included the kitchen, dining room, and living room. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to be furnished appropriately with adequate seating for residents. LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the six (6) residents currently residing there. Two (2) days of perishable food observed. The freezer is stocked with meats and frozen vegetables. Sharps are stored in locked kitchen island drawer. The residents’ medications and first aid kit were stored in locked kitchen cabinet next to glass door and were observed to be locked and inaccessible to residents. There are two (2) fire extinguisher on the floor in the kitchen next to medication cabinet and observed to be charged. The facility has a total of seven (7) bedrooms and five (5) bathrooms, The six (6) residents’ bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Tihesha Smith
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2026

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

FACILITY NAME: SERENITY MANOR LLC	FACILITY NUMBER: 197609888
	VISIT DATE: 02/22/2026

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(cont from 809)

had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed a supply of linens and hygiene supply in hall closet. Facility phone observed to be operational.

Each bathroom had the following items available: hand soap, paper towels, and trash cans. The hot water temperature was measured in bathrooms to ensure it was within the required range for residents’ comfort and safety. The water temperature range was measured at 119.8 and 123.7-degrees Fahrenheit for the bathrooms.

Attached Garage: contained laundry appliances observed to be in good repair. Additional supplies, incontinence supplies, and toxins stored and inaccessible to residents.

Pool in backyard is enclosed, locked and inaccessible. Backyard also has a shaded patio area and furniture observed to be in good condition.

Smoke detectors/carbon monoxide detector were tested and operable at time of visit.

At approximately 09:20 am, LPA Smith reviewed random files for residents and staff. Resident and staff files contained appropriate documentation.

Facility grounds were free of hazards /No Deficiencies cited

Exit Interview Conducted / A Copy of the Report Issued

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Tihesha Smith
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2026

LIC809 (FAS) - (06/04)

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