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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609921
Report Date: 04/02/2026
Date Signed: 04/02/2026 03:52:05 PM

Document Has Been Signed on 04/02/2026 03:52 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 SENIOR RETREATFACILITY NUMBER:
197609921
ADMINISTRATOR/
DIRECTOR:		PERERA, JILSKAFACILITY TYPE:
740
ADDRESS:26213 BEECHER LANETELEPHONE:
(661) 313-3030
CITY:STEVENSON RANCHSTATE: CAZIP CODE:
91381
CAPACITY: 6CENSUS: 5DATE:
04/02/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Anthony Errol Fendando, Co-Administrator TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analysts (LPAs) Angela Panushkina, Huma Rahimi, along with the Fire Inspector, Frank Madugno and Building Engineering Inspector, Robert Hagen, conducted an annual-continuation inspection and met with the Co-Administrator and explained the reason for the visit.

The facility is Fire Clearance was approved in 10/22/2019 for the capacity of one (1) Bedridden and one (1) Non-Ambulatory residents in room #1, two (2) Non-Ambulatory residents in room #2, one (1) Non-Ambulatory resident in room #3 and one (1) Ambulatory in room #4.

A tour of the physical plant was initiated at 10:15am and the following were observed:

The facility maintains a comfortable temperature at 68°F. The facility has four (4) bedrooms designated for residents’ use. All bedrooms are furnished with beds and dressers and required bedding and linen. The bedrooms have sufficient closet space and lighting. Auditory alarms were tested and observed to be operational. The team observed a twin bed in bedroom #1’ closet. The Co-Administrator informed the team that the staff are using the closet area as a resting area for breaks. The team also observed four (4) bottles of vitamins/over-the-counter medications along with Raid and disinfectant sprays placed on the table, unlocked inside the walking closet. Additionally, self-closing fire door hinge was loose/broken and had a stopper underneath the door to prevent from closing during the emergency. The Co-Administrator was informed to replace/repair the door. Lastly the team observed R1 had a full bed rail with no doctors' order/exception of file, double ½ (half) bed rails (making one full bed rail) for R2 with no doctors' order on file, ½ (half) bed rail for R4 with no doctors' order on file and ½ (half) bed rail for R3 with no doctors' order on file. Deficiency will be issued.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Angela Panushkina
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2026
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 SENIOR RETREAT
FACILITY NUMBER: 197609921
VISIT DATE: 04/02/2026
NARRATIVE
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There are three (3) full bathrooms. All bathrooms were observed to be clean and in good repair. Properly supplied with toilet paper, soap and paper towels. The hot water temperature measured at 113.2°F. Appropriate grab bar and non-skid mat were also observed. All trash cans in bathrooms had fitted lids to protect them from cross contamination. Extra towels and linens were readily available.

The facility has a kitchen area that is equipped with a refrigerator, microwave oven and sink. The team observed there to be sufficient stock of one-week perishable foods and two-day non-perishable foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. At 11:20am, LPAs observed twenty-one (21) prefilled syringes of ready-to-administer, single-dose unit narcotic medication prescribed for R1. The fire extinguisher is located in the kitchen and was last serviced on 07/25/2023. Deficiency will be issued.

At approximately 11:30am, LPAs observed medications are centrally stored and locked, in the kitchen cabinet, and inaccessible to residents in care. The first-aid kit has been inspected which has at least the following: tweezers, scissors, antiseptic, bandages, gauze, thermometer; including a current First Aid manual.

The laundry room is located by the garage. The washer/dryer appears to be in good condition. The laundry area was observed to be unlocked, and all laundry supplies and chemicals were accessible to residents in care. The team observed another twin bed in the garage. The Fire Inspector informed the Co-Administrator that the garage is not approved for a habitable space. Additionally, the Fire Inspector informed the Co-Administrator that the occupancy for the facility is incorrect, and new Fire Clearance is required at this time. The Deficiency will be issued.

These include a dining area and a living room. The Common areas are furnished with adequate furniture to accommodate a maximum capacity of six (6) residents. At 11:40am, smoke and carbon monoxide detectors were tested and observed to be operable. There were no visible immediate hazards.

At approximately 11:45am LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. LPA discussed the importance of maintaining care and supervision to meet the needs of clients. There are no bodies of water.

Between 12:30pm to 1:30pm, LPA reviewed records of six (6) residents and two (2) staff. Resident and staff records appeared to be incomplete (missing forms, signatures, dates and S1's & S2's initial training). Deficiency will be issued. LPA collected Certificate of Liability Insurance and LIC500.
Exit interview conducted. Appeal rights explained and copy of this report signed and delivered.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Angela Panushkina
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2026
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 04/02/2026 03:52 PM - It Cannot Be Edited


Created By: Angela Panushkina On 04/02/2026 at 02:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SERENITY SENIOR RETREAT
FACILITY NUMBER: 197609921

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(a)(2)(B&C)
Personal Accomodations and Services. (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room... (C) No bedroom of a resident shall be used as a passegeway to anothre room, bathe....

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and interviews, the licensee did not comply with the section cited above by placing a twin bed in bedroom #1 closet and twin bed in the garage by allowing the staff to use it as a resting/break room. This which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2026
Plan of Correction
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Administrator will remove beds from the closet and garage. Proof of pictures along with the statement of understanding this Section will be submitted to LPA by POC date.
Type A
Section Cited
CCR
87309(a)
Storage Spase and Access: (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation, the licensee did not comply with the section cited above by failing to lock the laundry and garage doors, where all chemicals and cleaning solutions were accessible to residents in care. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2026
Plan of Correction
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During today's visit, the Co-Administrator locked the doors. Licensee/Administrator agreed to provide in-service training to all staff. Copy of the training will be submitted to LPA by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Angela Panushkina
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/02/2026 03:52 PM - It Cannot Be Edited


Created By: Angela Panushkina On 04/02/2026 at 02:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SERENITY SENIOR RETREAT
FACILITY NUMBER: 197609921

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care: (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees for the supervision of the centrally strored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs inspection and observation, the licensee did not comply with the section cited above by failing to lock twenty-one (21) prefilled syringes of ready-to-administer, single-dose unit narcotic medication prescribed for R1 and four (4) over-the-counter staff medications in bedroom #1 closet. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2026
Plan of Correction
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During todays visit, all medications were immediately locked. Licensee/Administrator will hire a licensed vendor and provide training to all staff. Vendor's credentials (name, license #, telephone) will be submitted to LPA by POC date. Training certificate will be submitted to LPA upon completion.
Type A
Section Cited
CCR
87608(a)(3)
Postural Support: (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation and file review, the licensee did not comply with the section cited above in Based on LPAs observation and record review, the licensee did not comply with the section cited above by failing to obtain a written Doctor's order for three (3) half bed rails for R2, R3 and R4. This poses an immediate health, safety to persons in care.
POC Due Date: 04/04/2026
Plan of Correction
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License/Administrator agreed to obtain a written Dr. order. Copies of orders must be submitted to LPA by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Angela Panushkina
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2026


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 04/02/2026 03:52 PM - It Cannot Be Edited


Created By: Angela Panushkina On 04/02/2026 at 02:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SERENITY SENIOR RETREAT
FACILITY NUMBER: 197609921

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports: (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself... (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation and interview with the Co-Administrator, the licensee did not comply with the section cited above by having a full bed rail for R5 without an exception approval from the CCLD and proper Doctors order on file. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2026
Plan of Correction
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Licensee/Administrator will obtain a written Doctor's order for a full bed rail. Copy of Dr's order will be submitted to LPA by POC date.
Type A
Section Cited
CCR
87202(a)
Fire Clearance. a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Fire Marshal Inspector's observation, the licensee did not comply with the section cited above by failing to maintain the conditions of the approved fire clearance with a proper occupancy code and 2 fire doors (in bedroom #1 and garage) were broken/damaged/malfunctioning, which poses an immediate health and safety risk to residents in care. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2026
Plan of Correction
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Licensee/Administrator agreed to replace/fix two (2) fire doors and submit a request for change of occupancy through Building and Safety along with a new LIC200 with facility sketch to obtain a new Fire Clearance.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Angela Panushkina
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/02/2026 03:52 PM - It Cannot Be Edited


Created By: Angela Panushkina On 04/02/2026 at 03:06 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SERENITY SENIOR RETREAT
FACILITY NUMBER: 197609921

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b
Resident Records (b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on LPA file review, the licensee did not comply with the section cited above by not completing six (6) out of six (6) residnet files. Records were incomplete and or missing documents, which poses a potential health and safety risk to persons in care.
POC Due Date: 04/09/2026
Plan of Correction
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Licensee agreed to review and complete all facility residents' files. Written roster with resident name and date of file completion will be submitted to LPA by POC date.
Type B
Section Cited
CCR
87412(c)(1&2)
Personnel Records: (c) Licensees shall maintain in the personnel records verification of required staff training and orientation

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs record review, the licensee did not comply with the section cited above failing to provide proper training to all staff prior to employement. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/09/2026
Plan of Correction
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Licensee/Administrator agreed to provide in-service training to all staff (for the initial 20hrs) and submit copy of proof by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Angela Panushkina
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2026


LIC809 (FAS) - (06/04)
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