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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602285
Report Date: 11/02/2021
Date Signed: 11/02/2021 01:53:23 PM

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:
11/02/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:13 PM
MET WITH:Robin Aquino, House ManagerTIME COMPLETED:
01:55 PM
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Licensing Program Analyst (LPA) Galarza conducted an unannounced case management visit to check the health and safety of residents in care. The purpose of the visit was discussed with House Manager Robin Aquino.

LPA conducted a physical plant tour of the interior and exterior of the facility. Sufficient food supply was observed. Three (3) residents are receiving hospice care services. House manager stated she will submit an Exception for a hospice resident. NOTE: A hospice waiver increased was submitted and denied because the licensee is not in substantial compliance with health and safety and Title 22 code of regulations.

No health and safety concerns were observed during this visit. No deficiencies were cited.


Exit interview was held with House Manager Robin Aquino. A copy of the report was provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
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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