<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602285
Report Date: 08/23/2021
Date Signed: 08/23/2021 10:11:10 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:
08/23/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Robin Aquino, ManagerTIME COMPLETED:
10:15 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
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 Belen Taico. Facility Manager Robin Aquino arrived at the end of the visit.

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

HSC ยง1569.605 - Licensee failed to submit plan of correction proof of liability insurance to CCL on POC due date July 19, 2021 5:00 pm. As of today, DEFICIENCY IS NOT CLEARED. Civil Penalties were issued for period 8/13/21- 8/23/21. Total of 11 days, at $ 100.00 per day. The amount noted on Civil Penalty (LIC 421FC) is $ 1,100.00. A civil penalty of $100 per violation per day shall be assessed until the violation is corrected.

In addition, staff (S1) was observed to be working. Staff (S1) does not have a Caregiver Criminal Background clearance. Staff (S1) started work training at the home on Friday August 20, 2021.

Deficiencies are cited per Health & Safety Code Sections 1569.605 and Title 22.



LPA explained the citations, civil penalty assessment, and appeal rights.

Exit interview was conducted with Manager Robin Aquino. A copy of the report and appeal rights were provided. Manager signed the report stating "Appeal".
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/24/2021
Section Cited

1
2
3
4
5
6
7
Criminal Record Clearance. Prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption.

This requirement was not met by evidence of:
8
9
10
11
12
13
14
Based on staff records observation staff (S1) does not have clearance. Staff (S1) began working at the facility on Aug. 20, 2021.

Civil penalties are being assessed in the amount of $ 400.00.

This poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2