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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602285
Report Date: 02/03/2022
Date Signed: 02/03/2022 11:48:05 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:
02/03/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Belen Taico, CaregiverTIME COMPLETED:
11:55 AM
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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 Lead Caregiver Belen Taico. House Manager Robin Aquino was explained the purpose of the visit telephonically.

LPA conducted a physical plant tour of the facility.

  • Two (2) residents are receiving hospice care services.
  • COVID-19 Mitigation Plan was not printed or accessible to staff. House Manager emailed a copy and staff printed and placed it in a binder.
  • Accusation/CDSS No. 6120010302F was not observed to be posted as required by Law. The Accusation was on a clipboard, not readily accessible. Staff immediately posted it on the cork bulletin board in the dining room area.

  • Sufficient food supply was observed.
  • Shared room #1 had 2 beds. Per staff, the room is not presently occupied.
  • Rooms 2 and 3 did not have lamps. A deficiency was cited under complaint control #: 28-AS-20220128121943.


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


Exit interview was held with Lead Caregiver 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: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
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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