<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320181
Report Date: 12/09/2022
Date Signed: 12/09/2022 09:28:21 PM

Document Has Been Signed on 12/09/2022 09:28 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
EL SEGUNDO, 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: 4DATE:
12/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Jonathan EspirituTIME COMPLETED:
02:00 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 12/09/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with administrator Jonathan Espiritu and explained the purpose of today’s visit. The facility is licensed to operate for six (6) elderly ambulatory adults of which two (2) may be non-ambulatory. The facility is approved for two (2) hospice residents.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (4) resident's rooms, three (3) common bathrooms, a living area, a dining area, a kitchen, and an outside covered patio area.

LPA and licensee toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The hot water temperature was tested at 108.1 F. A comfortable temperature of 73 degrees was maintained in the facility.

LPA observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. The facility has several fire extinguishers that were charged, smoke detectors, and carbon monoxide was operable.The facility conducted a Fire/Safety Drill on 12/04/22. A working landline telephone remains available. The facility has a current liability insurance effective 06/09/22 - 06/09/23.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2022
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 4
Document Has Been Signed on 12/09/2022 09:28 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 12/09/2022 at 01:05 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SERENITY VILLA JJA, INC.
FACILITY NUMBER: 198320181

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on (observation) (record review)], the licensee did not comply with the section cited above. LPA identified (R3) no medical assessment (Physician's Report) on file. This volation poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2022
Plan of Correction
1
2
3
4
The licensee will adhere to Title 22 87458 and obtain a medical assessment for resident #3 (R3) a proof of correction must be submitted by fax to 323-981-1781 by POC due date: 12/30/22.
Type B
Section Cited
CCR
87412(a)(1-13)
87412 Personnel Records
a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:...


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on (observation) (record review), the licensee did not comply with the section. LPA identified staff #5 & staff #6 did not have a complete personnel file. This violaiton poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2022
Plan of Correction
1
2
3
4
Licensee will review 87412 Personnel Record and send complete file for each employee.
Proof of correction sent by fax 323-981.1781 to El Segundo Regional office by 12/30/22
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/09/2022 09:28 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 12/09/2022 at 01:17 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SERENITY VILLA JJA, INC.
FACILITY NUMBER: 198320181

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on (observation) (record review) the licensee did not comply with the section cited above. LPA identified Medication Administrationi Records were not maintained current and updated when meds are administered for residents in care. This violaiton which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2022
Plan of Correction
1
2
3
4
Licensee will ensure to retrain staff to ensure record keeping on medication administration is maintained accurate and in order for all residents in care. LIcensee will submit correction by fax to 323-981-1781 by 12/30/22.
Type B
Section Cited
CCR
87411(c)(1)
87411 Personnel Requirements - General
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on (observation) (record review), the licensee did not comply with the section cited. LPA identified staff #3 and staff #4 did not have current CPR First Aid. This vioilaiton poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2022
Plan of Correction
1
2
3
4
Licensee will ensure to adhere to Title 22 87411 and obtain CPR/First Aid for staff #3 and staff #5.
Proof of correction sent by fax 323-981.1781 to El Segundo Regional office by 12/30.22.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SERENITY VILLA JJA, INC.
FACILITY NUMBER: 198320181
VISIT DATE: 12/09/2022
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
26
27
28
29
30
31
32
INFECTION CONTROL:
During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed staff wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of the resident's and staff's vaccination records was conducted. The facility has a Mitigation Plan Report on file with CCLD.

DEFICIENCIES:
Based on interviews, observation, and record reviews, LPA identified staff #3 and staff #5 did not have complete employee files. LPA observed staff #3 and staff #5 did not have current CPR/First Aid Training certificates. LPA observed Medication Administration Records were not maintained in accurate and in order for residents in care. LPA identified resident #3 (R3) did not have physicians report on file.

Based on interviews, observation, and record reviews the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8,

Deficiencies are issued and an exit interview is conducted with Jonathan Espiritu. A copy of this report, appeal rights, and civil penalty were provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4