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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601630
Report Date: 08/14/2024
Date Signed: 09/10/2024 02:18:38 PM

Document Has Been Signed on 09/10/2024 02:18 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:SERENITY SENIORS HOME IIFACILITY NUMBER:
198601630
ADMINISTRATOR/
DIRECTOR:		ANTOINETTE RICHARDSONFACILITY TYPE:
740
ADDRESS:13302 TOWNE AVETELEPHONE:
(310) 715-1280
CITY:LOS ANGELESSTATE: CAZIP CODE:
90061
CAPACITY: 4CENSUS: 4DATE:
08/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:39 AM
MET WITH:AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:55 PM
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On 08/14/24 at 8: 39am, Licensing Program Analyst (LPA) Hollie Enriquez and Licensing Program Manager (LPM) Ulysses Coronel conducted an unannounced annual required visit using the CARE Inspection Tool. LPA and LPM met with administrator Antoinette Richards, Deanthony Hardiman, and DSP Krystal Hall and the purpose of today’s visit was explained. The facility is licensed to serve four (4) non-ambulatory residents ages 60 and above and may retain two (2) in hospice. Currently, the facility has four (4) residents, zero (0) of which are in hospice care. All residents are receiving serves through Regional Center-SCLARC.

The facility is a single-story home located in a residential neighborhood. The facility consists of the following: three (3) resident bedrooms, one (1) resident bathroom, dining area, kitchen, living room, laundry room, front and back yard, detached garage with shaded area.

LPA and LPM toured the physical plant with Administrator Hardiman and DSP Hall. LPA and LPM observed no bodies of water, firearms, or obstructions on the premises. Bedrooms were inspected and observed to have adequate lighting and storage for resident personal belongings. Beds with bedding supplies were in good condition. 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 water temperature measured 88-90.2 degrees F. The facility maintained a comfortable temperature during the time of the visit.

LPA and LPM observed the facility to be sanitary, appropriately furnished and in good repair at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there was a sufficient supply of perishable and non-perishable food that was properly stored. Fire extinguisher in kitchen area was charged, smoke detectors and carbon monoxide were tested and operable. Medications were stored, locked and inaccessible to

CONTINUED ON 809-C
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Hollie Enriquez
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2024
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 II
FACILITY NUMBER: 198601630
VISIT DATE: 08/14/2024
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LPA observed first aid kit to be compliant and with manual. A review of the Medication Administration Record (MAR) was complete and accurate. A landline telephone was in working condition and all mandated postings were observed.

During the visit, LPA and LPM observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPAs observed the facility has a supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

The facility has current liability insurance on file 08/11/2024 – 08/11/2025. The facility annual license fee will be due 08/20/2024. LPA provided PIN to Administrator to pay via online portal. Administrator Antoinette Richards license is current and expires 04/20/2025

Five (5) out of five (5) personnel files were reviewed and were observed as complete. Four (4) out of four (4) residents files were reviewed and observed and complete.


LPA and LPM tested the bathroom and kitchen water to measure 88-90 degrees F. Technical Advisory Note Issued.

An exit interview conducted with Administrator Deanthony Hardiman and a copy of report.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Hollie Enriquez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC809 (FAS) - (06/04)
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