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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320470
Report Date: 09/18/2025
Date Signed: 09/18/2025 04:25:13 PM

Document Has Been Signed on 09/18/2025 04:25 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: 4DATE:
09/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:23 AM
MET WITH:Deanthony HardimanTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 09/18/2025 Licensing Program Analyst (LPA) Jose Anguiano conducted an annual required visit and met with Deanthony Hardiman. The facility is approved for four (4) ambulatory residence, age ranges 60 and over and Hospice waiver for one resident. The facility is a single- story structure in a residential neighborhood. The facility consists of 2 bedrooms, 1 bathroom, staff room, living room, dining room, laundry, and backyard patio area with shaded seating. And detached garage and office space located in the back. LPA inspected inside and outside of the facility.

No bodies of water observed on the premises. All rooms inspected; beds, linens, lighting, and storage observed in good condition. Bathrooms operational with hot water measured at 117°F. Kitchen stocked with 2-day perishable and 7-day non-perishable food supply. Cleaning supplies, toxins, observed secured and inaccessible to clients. Facility was observed to be furnished, clean, and in good repair.

Fire extinguisher was charged. Smoke detectors and carbon monoxide detectors were operable. Infection control practices observed, including screening protocols and sanitizing stations. Required postings observed: Infection control signs, activity calendar, and food menu.

LPA reviewed 4 resident records and 4 staff records. Medication Administration Records (MARs) reviewed and found to be maintained in order. The License & Administrator was reminded of CCLD license fees that are overdue. Liability Insurance Certificate is valid and posted on the wall.

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Jose Anguiano
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2025
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SERENITY SENIORS HOME
FACILITY NUMBER: 198320470
VISIT DATE: 09/18/2025
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The following Technical Violation was noted during today’s visit:
LPA Jose Anguiano observed that a kitchen drawer containing knives was unlocked at the time of the visit. Although the drawer had a locking mechanism installed, it was not engaged, and the knives were accessible. Licensee was advised that all sharp objects must be kept inaccessible to residents at all times, per Title 22, Section 87468.2(c)(2). Licensee was reminded to ensure the locking mechanism is consistently used. This constitutes a technical violation and has been documented for follow-up during future visits.

Technical Violation issued on LIC 9102. Plan(s) of Correction discussed and developed with Eddreesha Mitchell. A copy of the report, LIC 9102, and Appeal Rights were provided. No deficiencies cited. Exit interview conducted and a copy of this report was given at the time of visit, Administrator.

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Jose Anguiano
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025
LIC809 (FAS) - (06/04)
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