Facility Evaluation Report, 09/03/2021 — Serenity Villa Jja, INC., San Pedro CA

Licensing Program Analyst (LPA) Ana Soto conducted an announced Pre-Licensing visit to this facility and was met with Jonathan Espiritu, Administrator. LPA also observed 3 care givers on duty at the time of the visit. The applicant is a corporation Jonathan Espiritu is the President/CEO of the corporation and designated administrator for the facility. This is a change of ownership application. The facility is currently operating as Serenity Guest Home IV #198204856 to Serenity Villa, INC. There are 5 residents at the facility. LPA Soto is conducting component 111 and Pre-licensing.

An application was submitted to Community Care Licensing Department (CCLD) on 01/22/2021 for an initial license for Residential Care For Elderly 60 years and above. The requested capacity is for (6) Residents,(0) ambulatory and (5) non-ambulatory and (1) bedridden. Structure: The facility is a one story beige stucco facility. It contains a front patio with a pergola and 2 tables and 4 chairs, 4 bedrooms and 2 1/2 bathrooms, back yard with garden and pool. Covered back patio, and 3 car attached garage. Signal System : Signal system in facility. Bedroom Residents: There shall be no more than two clients per bedrooms. bedrooms are designated resident bedrooms properly equipped with regulation guidelines of two beds, two chairs, two night stands, two lamps and overhead lighting. Presently, bedroom #1 & 3 are shared bedrooms and bedrooms #2 & #4 are private rooms. Bedroom Staff: No bedrooms will be used for awake staff. Bathrooms: 2 1/2 bathroom, 1/2 bathroom located next to kitchen. 2 full bathrooms, 1st bathroom is located in Bedroom #1 and the 2nd located in the hallway between rooms #2 -#4. The 2 full bathrooms have working toilets and wash basin, a walk-in shower with folding bench, grab bars, and mats. 1/2 bathroom has a working toilet and wash basin. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen is stored in the hallway closet.