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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602285
Report Date: 08/31/2021
Date Signed: 08/31/2021 02:26:53 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:
08/31/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Robin Aquino, ManagerTIME COMPLETED:
02:35 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 and to also conduct a health and safety check. The purpose of this visit was explained to Facility Manager Robin Aquino.

Discussion:


  • Licensee must submit to CCL by end of business day on Friday, September 3, 2021:

    • 1. Closure plan
    2. 60 Days Written Notice (draft for Residents/ draft for Family/ Responsible party)
    3. Transfer of P& I monies
    4. List of exempted staff
    5. List of utilities & vendors
    6. Admission Agreements, Medication Administration Records/Centrally Stored Medication and Destruction Records.
  • No new residents shall be admitted to the facility.
  • Staffing schedule and back-up staffing plans. Currently there are 2 staff working AM shift, 1 staff working PM shift, and 1 staff working the night shift.
  • Updated Emergency contact information.

Documents requested and obtained:
  • Physician Reports (emailed)
  • Medication Administration Record/Centrally Stored Medication and Destruction Records.
  • COVID-19 vaccination record card


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

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
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: 08/31/2021
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***Documents requested and not obtained due to printing/copying technical difficulties.
  • Admission Agreements


***Copies of Admission agreements shall be submitted to CCL by end of business day on Thursday, September 2, 2021. Failure to submit the documents requested will result in deficiencies.

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 8/24/21- 8/31/21. Total of 8 days, at $ 100.00 per day. The amount noted on Civil Penalty (LIC 421FC) is $ 800.00. A civil penalty of $100 per violation per day shall be assessed until the violation is corrected.

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: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
LIC809 (FAS) - (06/04)
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