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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320470
Report Date: 08/29/2024
Date Signed: 09/03/2024 04:08:08 PM

Document Has Been Signed on 09/03/2024 04:08 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:SERENITY SENIORS HOMEFACILITY NUMBER:
198320470
ADMINISTRATOR/
DIRECTOR:		RICHARDSON, ANTOINETTEFACILITY TYPE:
740
ADDRESS:14043 S NORTHWOOD AVETELEPHONE:
(310) 763-7879
CITY:COMPTONSTATE: CAZIP CODE:
90222
CAPACITY: 4CENSUS: 0DATE:
08/29/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:54 AM
MET WITH:Deanthony HardimanTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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On 08/29/2024 Licensing Program Analyst (LPA) Yolanda Rosser, and Wendy Gibbs conducted a scheduled prelicensing visit at the facility listed above. LPA’s met with Antoinette Richardson and Deanthony Hardiman and purpose of the visit was explained. Application was submitted for the Residential Care Facility Elderly on 01/30/2024. The facility has a Fire clearance for four (4) ambulatory residence.

Physical/Plant Structure The facility is a single - story structure in a residential neighborhood. The facility consists of 2 bedroom, 1 bathroom, staff room, living room, dining room, laundry, and detached garage and office space located in the back. LPA’s inspected inside and outside of facility. LPA’s observed all walkways to be free and clear of debris, hazards and obstruction. The gate exits from the backyard opens easily from the inside. There were no bodies of water observed on the premises.

Rooms: LPA’s observed all rooms to be clean and in good repair. LPA’s observed the rooms to have all the required furniture including, beds, nightstand, dresser, chairs, and ample storage space for personal belongings for residents personal belongings. All beds were observed with required linen including mattress coverings, fitted sheets, pillows, comforters. LPA’s observed an ample supply of linen in the hallway closet.

Kitchen: LPA’s observed the kitchen to be clean and sanitary. LPA’s observed all appliances to be operable and of good repair. LPA’s observed an ample supply of cookware, dishware and cutlery. LPA’s observed a Seven (7) day of non perishables, 3 day supply of perishables. There is a secured cabinet for cutlery located in the hallway. LPA measured water temperature , it measured between 105- 120 degrees. Laundry area had operable washer and dryer in good repair.

Common Rooms: Two couches to accommodate residence(s), reading material was observed on coffee table. Games and activities were observed in the cabinet in the common area. Dining room has large
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Yolanda Rosser
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SERENITY SENIORS HOME
FACILITY NUMBER: 198320470
VISIT DATE: 08/29/2024
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enough area to accommodate residence(s). All hallways were observed free and clear of hazards. All rooms had ample lighting. The facility was maintained at a comfortable temperature.

Bathroom: One bathroom, with a walk in shower and shower chair, with non skid mat and secured grab bars. Everything in the restroom was operable, clean and in good repair. The water temperature was measured at 110 degrees. There was hygiene supplies in the cabinet located in the hallway. Toilet was operable and in good repair.

Safety: Smoke and Carbon Monoxide detectors are operable. LPA’s observed two (2) fully charged fire extinguishers. One (1) mounted in the Livingroom, entrance area and the other and mounted near the laundry area. Last serviced July 11, 2024. LPA’s inspected and observed it to have all the required items and the manual. Cleaning supplies are located in a locked closet located in the hallway. LPA’s observed Medication and file cabinet for staff and residence files located in the staff room. Medication will be secured in a locked medication cart located in the staff room.

Component III: LPA’s reviewed and discussed Component III with the Administrator.

Advisory recommendations: Please email the following to the LPA:
CCL Sign


SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Yolanda Rosser
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC809 (FAS) - (06/04)
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