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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602285
Report Date: 11/17/2021
Date Signed: 11/17/2021 11:45:13 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: 3DATE:
11/17/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Belen Taico TIME COMPLETED:
11:50 AM
NARRATIVE
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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 staff Belen Taico. House Manager Robin Aquino was explained the purpose of the visit telephonically.

OBSERVATIONS:

  • Sufficient food supply was observed.
  • Two (2) residents are receiving hospice care services.
  • One (1) hospice resident, resident (R1) was observed to be uncovered in bed with only an incontinence diaper. The hospice care plan was reviewed; no physician order was observed indicating resident (R1) may be left only with incontinence diapers while in bed. The Physician's Report also did not have any notation regarding this.

Deficiency was cited.


Exit interview was held with staff Belen Taico. 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: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
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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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: 11/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/24/2021
Section Cited

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Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met by evidence of:
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Based on observation during today's visit hospice resident (R1) was observed laying in bed uncovered with only an incontinence diaper on and without pajamas covering the lower part of the body. Staff confirmed R1 is left in incontinence diaper while in bed if agitated per Hospice orders. However, it was not noted on the hospice care plan and MD report. This poses a potential health and safety risk.
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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: 11/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2021
LIC809 (FAS) - (06/04)
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