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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850567
Report Date: 06/05/2025
Date Signed: 06/05/2025 01:05:48 PM

Document Has Been Signed on 06/05/2025 01:05 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:SERENE LIVING HOME CAREFACILITY NUMBER:
565850567
ADMINISTRATOR/
DIRECTOR:		CERVANTES, ANALYNFACILITY TYPE:
740
ADDRESS:6437 KEYSTONE STTELEPHONE:
(805) 424-2779
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 6CENSUS: 0DATE:
06/05/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Analyn Cervantes / Leilani MilleraTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA), Martha Arroyo conducted a pre-licensing visit to this property at 10:00am. Upon arrival, the LPA met with Applicant Representative’s, Analyn Cervantes and Leilani Millera. During today's visit, the LPA completed Component III with the Applicant Representatives. Component II was completed on 04/24/2025.

The facility is one story. At approximately 10:10am, a physical plant tour was conducted inside and out. The LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. The applicant has obtained fire clearance for a total capacity of six (6) residents, five (5) non-ambulatory residents in bedrooms # 1 - #5 and one (1) bedridden resident in bedroom #2. There are no fire sprinklers in the facility. Main hallway leading to resident bedrooms from the living room was observed to be equipped with a fire door. The smoke alarms and carbon monoxide detectors are wired and function properly when tested. The LPA observed two (2) fire extinguishers fully charged with a date of 08/09/2024.

The facility has four (4) private resident bedrooms and one (1) shared resident bedroom. Bedrooms #1, #2, #3, and #5 will be single occupancy and bedroom #4 will be used for double occupancy. Each bedroom is equipped with a bed, nightstands, chests of drawers, chairs and closet space. The beds are furnished with comfortable mattress and clean linen, which includes, a mattress pad, top and bottom linens, pillowcases, blanket and a bedspread. Lighting in the rooms appeared adequate.

Report Continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2025
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
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SERENE LIVING HOME CARE
FACILITY NUMBER: 565850567
VISIT DATE: 06/05/2025
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Report Continued from LIC 809...

In addition, no bedroom was used as a passageway to another room, bath or toilet. Bedrooms #2, #4, and #5 have direct access to the outside perimeter. All rooms were free of odors. All window screens were clean and maintained in good repair. There is a closet located in the main hallway that stored an adequate supply of extra bed and bath linens. Facility will have a staff room which will be kept locked and inaccessible to residents.

The facility has two (2) bathrooms for resident use. Resident bathrooms contained appropriate non-skid mats and grab bars. Bathrooms have sufficient paper products. The LPA observed trash cans with tight fitting lids at the time of the visit. Hot water temperature in both bathrooms measured within the required range of 105 and 120 degrees Fahrenheit.

Medications will be stored and locked in a cabinet adjacent to the living room. First aid kit was observed to have bandages, thermometer, scissors, tweezers and a current first aid manual. Facility records will be maintained locked and inaccessible in a file cabinet adjacent to the kitchen.

The facility has at least seven (7) day supply of non-perishable food. The kitchen has a sufficient supply of plates, cups, cookware, and utensils. Enough seating for six (6) residents at the same time in the dining room table. Appliances in the kitchen were clean and all appeared functional at the time of the visit. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Kitchen knives and sharps were observed in a locked drawer next to the kitchen sink. Soaps and cleaning supplies will be locked and inaccessible under the kitchen sink. Trash cans had tight fitting lids. No flies or other vermin were observed.

The common areas were appropriately furnished, and the lighting was adequate. All window screens and coverings are in good repair. A working telephone is present. There is a television and other entertainment equipment, games and/or activity supplies in the living room.

Report Continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SERENE LIVING HOME CARE
FACILITY NUMBER: 565850567
VISIT DATE: 06/05/2025
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Report Continued from LIC 809C...

There is sufficient space to accommodate both indoor and outdoor activities. Night lights were observed in hallways and bathrooms. There is a fireplace in the living room that was observed to be adequately covered/screened. All doors had functioning auditory alarms at the time of the visit. The facility has required postings, including Licensing Complaint Poster, Resident Personal Rights, Theft and Loss Policy, and Resident Council Rights. No obstructions were observed inside or out.

The garage is attached to the house and will be kept inaccessible to residents in care. The washer and dryer was observed inside the garage. Cleaning supplies and personal hygiene items were observed in a locked cabinet at the time of the visit. There is a sufficient supply of emergency food and water. There will be no firearms/ammunition stored on the property. Facility has a generator for emergency purposes.

The exterior passageways were clean and clear of any obstructions. There are two (2) self-latching gates for emergency use. The LPA observed the backyard, which has a covered outdoor area and appropriate furniture for outdoor use. The outside area was observed to be large enough to conduct outdoor activities. There are no bodies of water noted at the time of the visit.

The physical plant of this facility location is in compliance with Title 22 regulations at this time.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

No corrections needed at this time. Exit interview conducted. The report was reviewed, and a copy was provided.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
LIC809 (FAS) - (06/04)
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