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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602285
Report Date: 09/28/2021
Date Signed: 10/20/2021 11:05:20 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SERENITY CARE HEALTH EVERGREENFACILITY NUMBER:
198602285
ADMINISTRATOR:OGBECHIE, BIOSEHFACILITY TYPE:
740
ADDRESS:131 SEGOVIA AVENUETELEPHONE:
(626) 699-4609
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY:6CENSUS: 4DATE:
09/28/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Robin Aquino, House ManagerTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Noemi Galarza, conducted an unannounced case management visit to this facility to ensure the Accusation/CDSS No. 6120010302E was posted as required by Law. In addition, to correct licensing reports originally issued on 7/16/2021, 7/29/2021, and 8/12/2021.

Upon arriving at the facility, the LPA met with staff Belen Taico Facility Manager Robin Aquino at 10:25 AM. The LPA explained the purpose for today’s visit. During today’s visit, a physical plant tour was conducted. Four (4) residents, two (2) staff, and one (1) hospice nurse were observed.

The Accusation was served to Licensee "Serenity Care Health EA Corporation" via certified mail on June 16, 2021. The Accusation was not observed posted in a conspicuous location on July 16, 2021. The Licensee did not provide written notification to the residents, their responsible parties, the long term care ombudsman, as required. A copy of the Accusation was provided to staff. Staff were instructed to immediately post the Accusation.



Civil penalties will be assessed against any facility that fails to take corrective action within the described time periods. Per the California Health & Safety Code Section 1569.38, you are hereby notified that a $100 civil penalty will be assessed for 7/16/21, Health & Safety Code Section 1569.38 requirements were not met. The total civil penalty for each day shall not exceed $100/day regardless of the number of notices the licensee fails to send that day. The total civil penalty for a continuous violation shall not exceed $5,000.

Civil penalties will accrue until Community Care Licensing has received proof that all required parties have received written notification of the revocation action.

(See LIC 809C for continuation of report)

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SERENITY CARE HEALTH EVERGREEN
FACILITY NUMBER: 198602285
VISIT DATE: 09/28/2021
NARRATIVE
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The following concerns were also observed during initial visit on 7/16/21:
  • At 9:51 am 2 knives were observed unlocked in 2 different kitchen drawers. Staff immediately locked the knives.
  • Based on staff records observation staff (S4) does not have clearance. Staff (S4) began working at the facility March 2021. Civil penalties were assessed in the amount of $ 500.00.
  • Based on records reviews Staff (S1-S3) are not associated to the facility. Staff (S1) began working at the facility in April 2021. Staff (S2) has worked at the facility since April 2019. Staff (S3) has worked at the facility since May 2021.


A copy of the report and appeal rights were provided.

Exit interview was conducted with Manager Robin Aquino. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SERENITY CARE HEALTH EVERGREEN
FACILITY NUMBER: 198602285
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/28/2021
Section Cited

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87705(f)(1) Care of Persons with Dementia. The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This poses and immediate health and safety risk to residents in care.
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Based on observation on 7/16/21 at 9:51 am 2 knives were observed unlocked in 2 different kitchen drawers. Staff immediately locked the knives.

This poses an immediate health and safety risk to residents in care.
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Type B
09/29/2021
Section Cited

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LIABILITY INSURANCE; COVERAGE REQUIREMENTS. On and after July 1, 2015, all residential care facilities for the elderly ... shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million citation continuation- ($3,000,000) in the total annual
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dollars aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement was not met, as evidenced by: Based on observations during initial visit 7/16/21, the licensee did not submit proof or verification of Liability Insurance. As of today's visit LPA has not obtained Liability Insurance verification.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SERENITY CARE HEALTH EVERGREEN
FACILITY NUMBER: 198602285
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/28/2021
Section Cited

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Criminal Record Clearance. Prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption.

This requirement was not met by evidence of:
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Based on staff records observation staff (S4) does not have clearance. Staff (S4) began working at the facility March 2021.


This poses an immediate health and safety risk to residents in care.
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Type A
09/28/2021
Section Cited

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Criminal Record Clearance. A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department.A signed Criminal Background Clearance Transfer Request, LIC 9182 (Rev. 4/02).
This requirement is not met as evidenced by:
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Based on records review conducted on 7/16/21, staff (S1-S3) are not associated to the facility. S1 began working at the facility in April 2021, S2 has worked at the facility since April 2019, and S3 since May 2021.

This poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SERENITY CARE HEALTH EVERGREEN
FACILITY NUMBER: 198602285
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/28/2021
Section Cited

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Posting of licensing reports; disclosure to new residents . A licensed residential care facility for the elderly shall provide written notice to a resident, the resident’s responsible party, if any, and the local long-term care ombudsman, within 10 days from the occurrence of either of the following events: The department commences proceedings to suspend or revoke the
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license of the facility pursuant to Section 1569.50. This requirement was not met as evidenced by: Based on observation and record review required parties have not been issued a written notice of the Accussation. Administrator Bioseh Ogbechie stated he could not confirm receipt of Accusation.
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Type B
09/28/2021
Section Cited

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Posting of licensing reports; disclosure to new residents. Upon providing the notice described in subdivision (b), the licensed residential care facility shall also post a written notice, in at least 14-point type, in a conspicuous location in the facility.... (1) The date of the notice. (2)The name of the residential care facility for the elderly.
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(3) A statement that a copy of the most recent licensing report ... (4) The name and telephone number of the contact person designated by the Community Care Licensing Division of the department to provide information on the license status of the facility. Based on observation on 7/16/21 the Accusation was not posted in a conspicuous location as required.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5