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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602285
Report Date: 08/12/2021
Date Signed: 08/12/2021 02:40:51 PM

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:
08/12/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Robin Aquino (Facility Administrator) via telephoneTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elizabeth Irra 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 by LPA Noemi Galarza. LPA was allowed entry to this facility by Belen Taico. The purpose of this visit was explained to Robin Aquino (Facility Administrator) 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. During today's visit, Ms. Aquino provided a copy of the letter sent to the Residents' Authorized Representative. Per Ms. Aquino, notifications were sent to Authorized Representatives via e-mail on 08/05/21. However, per Facility Administrator, Residents were not provided with a written notification. Additionally, Facility Administrator provided a copy of the letter that was sent to Ombudsman dated 08/02/21. However, the letter includes an incorrect office telephone number for CDSS Monterey Park Adult and Senior Care Program office and the letter is written as if the Ombudsman has loved ones residing at this facility ("Rest assured that the attentive care we provide to your loved ones will not be affected"). DEFICIENCY NOT CLEARED. Civil Penalties were issued for period 7/30/21- 8/12/21. Total of 14 days, at $ 100.00 per day. The amount noted on Civil Penalty (LIC 421FC) is $1,400.00.

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 7/30/21- 8/12/21. Total of 14 days, at $ 100.00 per day. The amount noted on Civil Penalty (LIC 421FC) is $1,400.00. A civil penalty of $100 per violation per day shall be assessed until the violation is corrected.

Civil penalties were assessed during today’s visit. An exit Interview was conducted with Ms. Aquino via telephone. A copy of the report, LIC 421FC and appeal rights were issued.

SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021
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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