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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602285
Report Date: 05/04/2022
Date Signed: 05/13/2022 02:09:34 PM


Document Has Been Signed on 05/13/2022 02:09 PM - It Cannot Be Edited

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: 5DATE:
05/04/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Bioseh Ogbechie, LicenseeTIME COMPLETED:
10:30 AM
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An Office Meeting was held via Microsoft Teams with Monterey Park, El Segundo, Woodland Hills, and Orange County Adult and Senior Care Regional Office staff of the Community Care Licensing Division (CCLD). The purpose of the meeting is to discuss the Stipulation, Decision and Order served on April 27, 2022. In attendance are: CCLD Regional Managers Araceli Ramirez, Benita Yates, Jill Nakata, and Marina Stanic; Licensing Program Managers (LPMs) Adeline Ho, Lisa Hicks, Janae Hammond, Jeralyn Pfannenstiel, Angela Kendrick, Eva Alvarez, Ulysses Coronel; and, Licensing Program Analysts (LPAs) Noemi Galarza, Joe Katrdzhyan, Stephanie Cifuentes, and Ashley Smith Morgan; and, Licensee Bioseh Ogbechie, as well as Licensee Representative for Serenity Care Health EA Corporation, Binko Corp and Serenity Care Health Corporation, Nicolas Spigner.

DISCUSSION:

It was addressed that the license to operate Serenity Care Health Evergreen by Serenity Care Health EA Corporation shall be revoked. However, the revocation of this license is stayed for a 90-day period in order for the licensee to facilitate the potential sale and/or transfer of the facility to a third party without creating a lapse in licensure that would otherwise result in the relocation of facility residents.

The Licensee was reminded that if an extension of the Stay Period is required to complete the sale and/or transfer of the facility, the licensee must submit a request for the thirty (30) day extension in writing no later than June 27, 2022. If the licensee fails to request an extension, the license to operate Serenity Care Health Evergreen by Serenity Care Health EA Corporation will be revoked effective July 28, 2022.

The Licensee was also reminded that a prospective buyer or transferee must apply for and be granted a new license for this location. The Licensee communicated that they have a potential buyer that has expressed interest in submitting an application for licensure. Licensee stated that at this time, the potential buyer plans on submitting an application by Friday, May 6, 2022.

See LIC 809C for report continuation
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022
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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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: 05/04/2022
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It was addressed that the Licensee will comply with procedures set forth in Health and Safety Code 1569.682 regarding closure plans. A copy of the Health and Safety Code 1569.682 will be provided to the licensee to ensure that all aspects of the Health and Safety Code are followed.
  • The Licensee shall issue an approved 60-day written notice to residents and their responsible parties by today, May 4, 2022. The notice shall include all of the following:

    • The reason for the eviction, with specific facts to permit a determination of the date, place, witnesses, and circumstances concerning the reasons.
    • A copy of the resident’s current service plan.
    • The relocation evaluation.
    • A list of referral agencies.
    • The right of the resident to resident’s legal representative to contact the department to investigate the reasons given for the eviction pursuant to Section 1569.35.
    • The contact information for the local long-term care ombudsman, including address and telephone number.
    • Upon issuing the written notice of eviction, a licensee shall not accept new residents or enter into new admission agreements.
    • Refund any preadmission fees, as documented in Health and Safety Code 1569.682.

  • The Licensee plans to issue 60-day notices to residents' and their responsible parties today May 4, 2022.

  • The licensee shall prepare, for each resident, a relocation evaluation of the needs of that resident, which shall include both of the following:
      • (A) Recommendations on the type of facility that would meet the needs of the resident, based on the
      current service plan.
      (B) A list of facilities, within a 60-mile radius of the resident’s current facility, that meets the resident’s
      present needs.

See LIC 809C for report continuation
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
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
VISIT DATE: 05/04/2022
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  • The licensee shall assist residents who have no relatives or responsible parties in contacting community resources that can arrange for a new placement, if necessary. They shall not solicit, request or accept fess, payments or gratuities from the residents, their relatives or responsible parties or placing agencies for any placement assistance or referrals by Respondents to a new facility.
  • The licensee shall forward to the Department a list of all residents who have been served with the notice to relocate, as well as the name, address, and telephone number of the place to which each resident has been relocated.
  • The licensee acknowledges that, pursuant to Health and Safety Code section 1569.682 (d)(2), the participation of the Department and local agencies in the relocation of residents from a residential facility for the elderly does not relieve the licensees of any responsibility under this section. Licensees that fail to comply with the requirements of this section shall be required to reimburse the Department and local agencies for the cost of providing the relocation services or the costs incurred in care for the residents through the use of a temporary manager or receiver. If the licensees fail to provide the relocation services required in this section, then the Department may request that the Attorney General’s office, the city attorney’s office, or the local district attorney’s office seek injunctive relief and damages.
  • Licensee representative, Ogbechie’s certification of an administrator is revoked upon the Department’s adoption of this Stipulation as its Decision and Order. The revocation of this certification shall be STAYED to facilitate the sale or transfer of the Facilities, subject to the limitations and conditions specified in paragraph 2 of the Stipulation. After the end of the Stay Period referenced in paragraph 2, Ogbechei’s administrator certificate shall be revoked for the remainder of Ogbechie’s life.
  • For the balance of the licensee representative, Ogbechie’s life, Ogbechie shall not apply for, receive or hold any license or certification to operate any facility subject to the Departments licensure authority; or apply for or be approved as a resource family (as defined in section 1517(a) of the Health and Safety Code and section 16519.5 of the Welfare and Institutions Code.
  • The licensee is still responsible for the payment of civil penalties, monitoring fees and any actions arising out of an audit or other review to establish, modify, preserve, enforce, or to recover an overpayment or to reimburse an underpayment of public or private funds.


See LIC 809C for report continuation
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: 05/04/2022
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Until the date that the license to operate Serenity Care Health Evergreen by Serenity Care Health EA Corporation is revoked, the licensee shall operate in compliance with all applicable statues and regulations. Violation of any licensing law that threatens the immediate health and safety of residents in care may be remedied at the discretion of the Department by the immediate suspension of the licensee’s licenses pursuant to Health and Safety Code section 1569.50.

At this time, no Plan of Corrections are required.



The documents listed below were requested from the Licensee Representative and it was confirmed that copies will be provided to CCL by the end of business day on Friday May 6, 2022.
    1. Name of potential buyer. Licensee stated the potential buyer will be the same for all facilities.
    2. If applicable, provide resident relocation information.


An exit interview was conducted, and a hard copy of the report was emailed. The Licensee shall furnish a signed report to the LPA.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
LIC809 (FAS) - (06/04)
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