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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602285
Report Date: 05/12/2022
Date Signed: 05/12/2022 01:15:50 PM


Document Has Been Signed on 05/12/2022 01:15 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:
05/12/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Belen Taico, House ManagerTIME COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Galarza and Yating Yang conducted an unannounced case management visit to check the health and safety of residents, and to ensure Stipulation CDSS No. 6120010302F was posted as required by Law. LPA explained the purpose of the visit to staff Belen Taico.


LPA conducted a physical plant tour of the facility.
  • Three (3) residents are receiving hospice care services.
  • Stipulation #: 6120010302F was observed posted as required by Law. It was posted and readily accessible.
  • LPA spoke to Stephanie Perez, Director of Assisted Living Operations. She stated that a revised 60-day Notice was mailed out to responsible parties/authorized representative's on May 4, 2022.
  • One (1) family member confirmed via phone call that the 60-Day Notice was received last week.


No health and safety concerns were observed during this visit.


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: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
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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