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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320181
Report Date: 09/03/2021
Date Signed: 09/10/2021 09:43:57 AM

Document Has Been Signed on 09/10/2021 09:43 AM - 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:SERENITY VILLA JJA, INC.FACILITY NUMBER:
198320181
ADMINISTRATOR:ESPIRITU, JONATHANFACILITY TYPE:
740
ADDRESS:1036 VIA LA PAZTELEPHONE:
(310) 521-0043
CITY:SAN PEDROSTATE: CAZIP CODE:
90732
CAPACITY: 6CENSUS: 5DATE:
09/03/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jonathan Espiritu, AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Ana Soto conducted an announced Pre-Licensing visit to this facility and was met with Jonathan Espiritu, Administrator. LPA also observed 3 care givers on duty at the time of the visit. The applicant is a corporation Jonathan Espiritu is the President/CEO of the corporation and designated administrator for the facility. This is a change of ownership application. The facility is currently operating as Serenity Guest Home IV #198204856 to Serenity Villa, INC. There are 5 residents at the facility. LPA Soto is conducting component 111 and Pre-licensing.

An application was submitted to Community Care Licensing Department (CCLD) on 01/22/2021 for an initial license for Residential Care For Elderly 60 years and above. The requested capacity is for (6) Residents,(0) ambulatory and (5) non-ambulatory and (1) bedridden. Structure: The facility is a one story beige stucco facility. It contains a front patio with a pergola and 2 tables and 4 chairs, 4 bedrooms and 2 1/2 bathrooms, back yard with garden and pool. Covered back patio, and 3 car attached garage. Signal System: Signal system in facility. Bedroom Residents: There shall be no more than two clients per bedrooms. bedrooms are designated resident bedrooms properly equipped with regulation guidelines of two beds, two chairs, two night stands, two lamps and overhead lighting. Presently, bedroom #1 & 3 are shared bedrooms and bedrooms #2 & #4 are private rooms. Bedroom Staff: No bedrooms will be used for awake staff. Bathrooms: 2 1/2 bathroom, 1/2 bathroom located next to kitchen. 2 full bathrooms, 1st bathroom is located in Bedroom #1 and the 2nd located in the hallway between rooms #2 -#4. The 2 full bathrooms have working toilets and wash basin, a walk-in shower with folding bench, grab bars, and mats. 1/2 bathroom has a working toilet and wash basin.Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen is stored in the hallway closet.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2021
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SERENITY VILLA JJA, INC.
FACILITY NUMBER: 198320181
VISIT DATE: 09/03/2021
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Emergency Phone Numbers, Exit Plan, & Menu: Emergency numbers and menu are posted and readily available for review: menu on the kitchen refrigerator and emergency numbers posted on the hallway wall in front of the front entrance. Facility has a land line telephone located in the office space next to the dining room. 3 Fire extinguishers, 1 in the kitchen area which is labeled and 2nd next to the front entrance also labeled, and 3rd in the garage, they are tagged with current annual checks. Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in locked storage drawers in the kitchen cabinets. Adequate food supply is stored in kitchen and garage and consists of the following: 2 day perishables, and 7 week non-perishables. Smoke Detectors: There are 7 currently being hard wired smoke detectors. Carbon monoxide detector near room #1. Appliances: Stove burners, oven, microwave, freezers and washers/dryers are in working condition. The residence is equipped with central heat and air conditioning. There is 1 thermostat's for the facility to regulate the temperature for all residents. Toxins: Cleaning supplies, and toxins are stored in the garage. Water Temperature: Water was tested in the 1/2 bathroom it's within 105-120 degrees Fahrenheit range 109 degrees fahrenheit. Medication, First-Aid Kit & Book: Designated area for centrally stored medication is located the cabinet in the office space. A first-aid kit has been inspected which has at least the following: thermometer, tweezers ,scissors, antiseptic, bandages, gauze and current first aid manual, which stored on top of cabinet in the office space , available for staff use but inaccessible to residents. Residents & Staff Files: Designated area for files are located in the cabinet in the office space. Pools/Jacuzzi & Pets: There is a pool and it has a gate with lock, it's inaccessible to residents. There is one dog on these premises. Common areas: Toured common areas including dining room and living room. The dining room has a sliding glass exit door, which exits to the backyard with operational alarm. Adequate furniture and seating accommodations for the requested capacity. LPA observed mid-size screen TV in the living room. Fire Clearance: Fire clearance does indicate delayed egress and/or locked perimeter. Component III was conducted at the time of the visit.

There are no corrections to be made. Due to technical difficulties, reports were emailed to Administrator.



An exit interview was conducted and a copy of this report has been furnished to the applicant via email for signature. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021
LIC809 (FAS) - (06/04)
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