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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602285
Report Date: 10/07/2021
Date Signed: 10/07/2021 09:36:10 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: 4DATE:
10/07/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Belen Taico, StaffTIME COMPLETED:
09:40 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 Analysts (LPA) Galarza and Jewel Baptiste 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 Belen Taico. Two (2) caregivers were observed during 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 18, 2021. As of today, DEFICIENCY IS NOT CLEARED. Civil Penalties are being issued for period 9/24/21- 10/7/21. Total of 9 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.

Deficiencies are cited per Health & Safety Code Sections 1569.605.



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

Exit interview was conducted with staff Belen Taico. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
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 1