Serenity Living Board & Care

Type of visit: Case Management - Other

In conjunction with complaint investigation, Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted a case management visit to address the deficiencies unrelated to the complaint. Later Assistant Administrator arrived and informed LPA and S2 that they will not be able to join today’s visit and granted S2 permission to sign this report. Prior to this visit during Complaint Investigation on 07/08/26, LPA Alvizar-Ettima reviewed resident R1’s physician report and noted that it was not signed by resident and resident’s physician. The Assistant Administrator was advised that the licensee shall obtain a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year. The complete document shall be part of the resident's record. At the time of this visit Assistant Administrator indicated that they signed it and it was the only physician report that they had in R1’s record file. During this licensing visit, LPA Alvizar-Ettima discovered that staff#1, (S1) Tamara Selivanova Borisovna DOB: 07/06/1967 have been present without a Criminal Background Clearance and not Association to this facility. S1 has been working at facility since 06/24/26 providing care to the residents. The Assistant Administrator and S1 indicated that S1 only work four (4) days since they have been hired. LPA requested S1’s Identification Card and S1 stated that they did not have it and had already provided it to Assistant Administrator. Later, Assistant Administrator illustrated LPA S1’s picture of their California Identification card. LPA reviewed Licensing database and Criminal Background System and S1’s names did not appear on Serenity Living Board & Care facility record. S1 immediately left the facility. Assistant Administrator was advised that S1 cannot return until they have approved Criminal Background Clearance and Association to this facility. The Assistant Administrator acknowledged understanding. No health and safety concerns were identified. Under Title 22, Division 6. Chapter 8, following Citations and civil penalty were issued and recorded on LIC809D. Exit interview was conducted, appeal rights provided and a copy of report was issued.the state’s words, verbatim · CDSS document, Jul 17, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(3)(c) · Plan of correction due date: Jul 18, 2026

87355 Criminal Record Clearance. (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing, or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement is not met as evidenced by staff #1 working in the facility since 11/10/25 and had no criminal record/ association to the facility. This poses an immediate hazard to the health and safety to residents in care.the state’s words, verbatim · CDSS document, Jul 17, 2026

Plan of correction: Assistant Administrator agreed that Staff #1 (S1) will not return until they have approved Criminal Background Clearance and Association to this facility. S1 immidiatelty left the facility and POA was cleared during today's visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87458(a) · Plan of correction due date: Jul 24, 2026

87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. This requirement was not meet as evidenced by. R1’s physician report was not signed by the doctor. This poses potential risk to health, safety and personal rights to residents in care.the state’s words, verbatim · CDSS document, Jul 17, 2026

Plan of correction: Assistant Administrator agreed to obtain Medical Assessment signed by their physician and person prior to acceptance as a resident. R1 no longer resides in the faciltiy and POA was cleared during today's visit

Type of visit: Prelicensing

On 6/4/2026 at 11:00am Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted an announced Pre-Licensing Inspection at the facility. Upon arrival LPA met with the Administrator Sherwood Dustina, introduced herself, showing the department badge and conducted an entrance interview. Fire Clearance was approved on 4/14/2026 for a maximum capacity of six (6) residents, of which two (2) may be ambulatory, three (3) non-ambulatory and one (1) resident approved for bedridden for bedrooms #2 and #4. This is a single-story house with four (4) bedrooms and three (3) bathrooms. Three (3) bedrooms are designated for residents’ use, and one (1) room for staff use only. Facility will have an awake night shift staff on premises. At 11:30 am a physical plant was toured inside and out of the property with the assistance of the Administrator and the following was observed: KITCHEN: The facility has an open kitchen area that is equipped with a new refrigerator, microwave oven and sink. At 11:55am, LPA observed adequate supplies of nonperishable food properly stored in the cabinets. Perishable food items are not required at this time as there are no residents in the facility. LPA observed dining ware to accommodate a maximum capacity of six (6) residents. All knives and sharps are observed to be locked inside a kitchen cabinet and inaccessible to residents in care. The facility has one (1) new fire extinguisher which was purchased on 9/23/2025. Continue on LIC809-C Laundry Area: A functioning washer and dryer are located inside the garage. Disinfectants, laundry detergents, and hygiene supplies will be stored securely in a garage as well. COMMON AREAS: At 11:50am LPA observed the living/family room and dining room furniture to be clean and in good repair. The facility maintains a comfortable temperature at 73°F. The air conditioner is operational. No firearms observed or will be maintained on the premises. Licensee has ordered puzzles, books, balls, and board games to provide activities to clients in care. No obstructions and or tripping hazards observed throughout the facility. Bedrooms: There are four (4) bedrooms in the facility, of which three (3) are designated for residents’ use only. Bedrooms are furnished and well equipped with beds, nightstands, chairs, dresser, bedding, pillowcase, mattress pad, and blankets; extra linen is available inside the linen closet located in the hallway. Rooms were observed to have sufficient lighting and closet space. LPA observed appropriate window screens. Sufficient supplies of personal hygiene products stored in the storage area and will be provided to the clients by the Licensee. Facility will have an awake staff. BATHROOMS: The facility has three (3) bathrooms, all bathrooms are designated for residents’ and staff use. Bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured at 12:00pm to be at 107.4F degrees. SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. At 12:05pm they were tested and observed to be operational. Facility has phone which was checked at 12:02pm to be operational. Medications: LPA observed medications will be kept centrally stored and locked inside the kitchen cabinet next to the gas stove. The key cannot be accessible to residents in care. Clients and staff files will be kept inside the commercial locket cabinet located in the office area next to bedroom #4. Continue on LIC809-C SURROUNDING GROUNDS: The facility has sufficient yard space. LPA observed the backyard with appropriate outdoor furniture and covered shaded areas for clients. LPA discussed the importance of maintaining care and supervision to meet the needs of clients. During the physical walk through LPA observed all exit areas to be free of clutter and obstruction. There is no water in the promises. GARAGE: LPA observed that laundry machines are installed inside the garage, which will also be used for storage. An additional refrigerator is present as well. Component III was conducted with the Licensee/Administrator. Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) and will be notified by the CAB Analyst when the license has been approved. LPA collected copy of the Administrator Certificate – Exp date: 1/20/2027. LPA also informed Administrator to update the new form of the Emergency Disaster Plan and submit it to the department. Exit interview was conducted, a copy of this report signed and delivered to the Administrator.the state’s words, verbatim · CDSS document, Jun 4, 2026

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 6 Census (if any clients in care): 0 COMP II Participants: Elizabeth M Kazanchian and Dustina Sherwood Interview Method: Telephone interview On 05/12/2026, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, May 12, 2026