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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320540
Report Date: 12/20/2024
Date Signed: 12/20/2024 12:18:38 PM

Document Has Been Signed on 12/20/2024 12:18 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:SERENITY FAMILY HOME CAREFACILITY NUMBER:
198320540
ADMINISTRATOR/
DIRECTOR:		GARCIA, JASMINFACILITY TYPE:
740
ADDRESS:2653 W 225TH STREETTELEPHONE:
(310) 325-1735
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY: 6CENSUS: 5DATE:
12/20/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Pampee MejiaTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 12/20/24, Licensing Program Analyst (LPA), Regina Cloyd, conducted an announced visit to the facility for purpose of a prelicensing evaluation. An application was submitted to CCLD on 09/11/2024, for Change of Ownership for a Residential Care Facility for the Elderly to serve the Elderly for ages 60 years and older. The requested capacity is for six residents, four (4) non-ambulatory and two (2) bedridden. Bedroom #5 is designated for two bedridden residents.

Structure:
Facility is a five (5) bedroom, three (3) bathroom, single story house with an attached car garage. It includes a kitchen and dining and living room. There is a shaded porch area on the premises. The residents’ bedrooms are spacious and will easily accommodate the residents’ furnishings.
Bedrooms Residents:
Bedrooms #1 – 4 are for non-ambulatory residents. Bedroom #5 is for two (2) bedridden residents. Bedrooms have beds, chairs, nightstands, adequate lighting, and dressers and/or closets.
Bathrooms:
All three (3) bathrooms have a working toilet, wash basin, bath-tub/shower. Bedrooms #1 – 2 have private bathrooms. Continue to LIC809-C.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2024
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SERENITY FAMILY HOME CARE
FACILITY NUMBER: 198320540
VISIT DATE: 12/20/2024
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Linens & Hygiene Supplies:
Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in closet hallway.Emergency Phone Numbers, Exit Plan & Menu:
The facility has an active landline.
Fire Extinguisher located in the dining room mounted on wall, a second extinguisher is located in the garage.
Food Service:
Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked drawer next to the sink. Food supply adequate stored in the kitchen and in the garage. Dishwasher in kitchen properly installed and functioning.
Smoke Detectors:
The smoke detectors and carbon monoxide are operational and interconnected.
Appliances:
Stove burners, oven, microwave, washer, and dryer working. There are two refrigerators in the home, one in the kitchen and one in the garage for additional food storage. Each refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. The residence is equipped with central air and heat.
Toxins:
Locked in kitchen cabinets.
Water Temperature:
Tested at 118 degrees.
Continue to LIC809-C.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SERENITY FAMILY HOME CARE
FACILITY NUMBER: 198320540
VISIT DATE: 12/20/2024
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Medications, First-Aid Kit & Book:
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 are stored in medication cabinet, available for staff use but inaccessible to residents.
Clients & Staff Files:
Records of staff and residents are stored in a locked cabinet in the dining room. Records were inspected.
Reading Material, Games, Equipment & Materials:
The facility has board games, books, and other recreational materials for the residents' use.
Fire clearance:
Fire Clearance with the following special conditions: rooms approved for non-ambulatory/bedridden, approval of delayed egress or delayed egress with secured (locked) perimeter was approved on 11/12/2024.
Pre-licensing Checklist:
Completed by licensee and reviewed by LPA.

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance.
During the prelicensing inspection certain items were observed which do not comply with applicable laws and regulations; the following items must be corrected and proof of correction shall be submitted to the CCLD office to the attention of LPA by 01/07/2025. Continue to LIC809-C.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SERENITY FAMILY HOME CARE
FACILITY NUMBER: 198320540
VISIT DATE: 12/20/2024
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If additional time is required to complete noted items to correct, then the applicant will request an extension in writing prior to the due date. Some items may require a follow up inspection for verification of correction.

Prelicensing:
1. Plan of Operation was not available for review.
2. Administrator to add night lights in the passageway to nonprivate bathroom.
3. Administrator to remove obstructions from the perimeter of the facility.
4. Administrator to have a complete personnel file on site.
5. Administrator to submit page 5 of Emergency Disaster Plan.
6. The Licensee to submit general liability insurance for Serenity Family Home Care.
7. Administrator to post Theft & Investigative Procedures.
8. Administrator to post RCFE Complaint Poster (20” x 26”).
9. Administrator to add assembly points from Emergency Disaster Plan to Facility Sketch.

An exit interview was conducted and a copy of this report has been furnished to the applicant’s assistant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
LIC809 (FAS) - (06/04)
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