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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602285
Report Date: 07/29/2021
Date Signed: 07/30/2021 08:22:42 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: 6DATE:
07/29/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Clara Mukutigwa, StaffTIME COMPLETED:
01:05 PM
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Licensing Program Analyst (LPA) Galarza conducted an Unannounced Plan Of Correction (POC) visit to follow up on the Plan of Correction citations issued during the 7/16/2021 case management visit. The purpose of this visit was explained to caregiver staff Clara Mukutigwa. Facility Manager Robin Aquino was explained the purpose of the visit via telephone.

On 7/16/2021 the facility was cited for:

HSC §1569.38(g) - Licensee failed to comply with plan of correction 1569.38(b)(1) requiring all required parties [resident's responsible parties and Long Term Ombudsman] be given written notification of Accusation/CDSS No. 6120010302F. No proof was submitted. POC was due on 7/17/21. NOTE: Civil penalties will accrue until Community Care Licensing has received proof that all required parties have received written notification of the revocation action. DEFICIENCY NOT CLEARED. Civil Penalties were issued for period 7/17/21 - 7/29/21. Total of 13 days, at $ 100.00 per day. The amount noted on Civil Penalty (LIC 421FC) is $ 1,300.00. A civil penalty of $100 per violation per day shall be assessed.

HSC §1569.605 - Licensee failed to submit plan of correction proof of liability insurance to CCL on POC due date July 19, 2021 5:00 pm. DEFICIENCY NOT CLEARED. Civil Penalties were issued for period 7/20/21- 7/29/21. Total of 10 days, at $ 100.00 per day. The amount noted on Civil Penalty (LIC 421FC) is $ 1,000.00. A civil penalty of $100 per violation per day shall be assessed until the violation is corrected.

CCR 87355(e)(1) - Licensee failed to submit proof that staff (S4) applied for a Criminal Record Background Clearance live scan. On 7/20/2021, LPA received email notification that staff (S4) resigned on 7/16/21 and did not get fingerprinted. POC due date was 7/17/21. Civil Penalties were issued for period 7/18/21 - 7/20/21. Total of 4 days, at $ 100.00 per day. The amount noted on Civil Penalty (LIC 421FC) is $ 300.00. A civil penalty of $100 per violation per day shall be assessed.

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: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
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
VISIT DATE: 07/29/2021
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CCR 87355(c)(1) - Licensee failed to submit proof of correction that staff (S1-S3) have completed a Criminal Backgroud Transfer Request and associated to the facility. Licensee was provided a POC due date of 7/17/21. On 7/20/2021, LPA received email notification that staff (S1-S3) were associated, but proof was not submitted. DEFICIENCY NOT CLEARED. Civil Penalties were issued for period 7/18/21 - 7/29/21. Total of 13 days, at $ 100.00 per day. The amount noted on Civil Penalty (LIC 421FC) is $ 1,200.00. A civil penalty of $100 per violation per day shall be assessed.

***Civil penalties were assessed during today’s visit.

Due to technical difficulties with printing the report was emailed to House Manager Robin Aquino.

An exit Interview was conducted with Clara Mukutigwa. A telephonic exit interview was conducted with House Manager Robin Aquino. A copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
LIC809 (FAS) - (06/04)
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