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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320181
Report Date: 09/05/2024
Date Signed: 09/05/2024 11:20:51 AM

Document Has Been Signed on 09/05/2024 11:20 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:SERENITY VILLA JJA, INC.FACILITY NUMBER:
198320181
ADMINISTRATOR/
DIRECTOR:
ESPIRITU, JONATHANFACILITY TYPE:
740
ADDRESS:1036 VIA LA PAZTELEPHONE:
(310) 521-0043
CITY:SAN PEDROSTATE: CAZIP CODE:
90732
CAPACITY: 6CENSUS: 3DATE:
09/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Allia Mangubat/ Jonathan EspirituiTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Sparkle Day conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one-year inspection. LPA met with Allia Mangubat ,caregiver and the purpose of the visit was discussed. During this visit Administrator Jonathan Espiritu arrived and assisted with the visit. The facility is licensed to serve 6 residents ages 60 and above of which 2 can be non amb. There is also an approved hospice waiver for 2 residents. One of the residents are diagnosed with dementia. One resident receives hospice care services. The facility does not handle any of the residents’ money.

This home is a single story home consisting of: (4) resident bedrooms, (3) bathroom, living room, kitchen with dining area, laundry room (located in the attached garage) and an outdoor shaded patio area. LPA toured the resident bedrooms and observed the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured between 106.1F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions.

Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured There is a fenced pool. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

During todays visit LPA did not observe any deficiencies.

Exit interview conducted with Jonathan Espiritui, Administrator and a copy of this report was given .

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Sparkle Day
LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2024
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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