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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602870
Report Date: 05/19/2021
Date Signed: 05/19/2021 03:25:49 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:SERENTO CASAFACILITY NUMBER:
198602870
ADMINISTRATOR:KNEEDY-CAYEM, KARAFACILITY TYPE:
741
ADDRESS:1740 SAN DIMAS AVENUETELEPHONE:
(909) 394-0304
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:131CENSUS: 47DATE:
05/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Administrator, Sara SesayTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Tony Vasallo and Nina Galarza conducted an annual required visit. LPA's met with administrator, Sara Sesay and explained the reason for the visit. LPA's used the infection control tool to evaluate the facility. LPA's observed the facility plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed resident and staff files. Facility has an approved mitigation plan

Six (6) resident bedrooms were randomly chosen for review and were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. The bathrooms have the required grabs bars and non-skid materials in the shower. The hot water was between 108 - 112 degrees which is within the required 105 - 120 degrees. The kitchen was inspected. It's a large commercial kitchen with a walk-in refrigerator and freezer. There is sufficient perishable and non-perishable food. All the appliances are cleaning and working properly. The refrigerator and freezer were set at appropriate temperatures. Common areas such as the dining room, hallways, resident lounges, library, stairways, elevators, and sitting areas in assisted living and dementia unit were inspected. All areas were clean and had the required furniture. The outside patio areas have shaded sitting areas. Facility was observed following COVID-19 procedures such as visitor assessments, cleaning, and wearing PPEs.

LPA's reviewed 6 resident files to confirm emergency contact is updated. LPA's also reviewed staff files to confirm health screenings and fingerprint clearances. All staff files reviewed were fingerprint cleared. LPA's randomly chose some residents' medications to review. Medications are documented properly and stored appropriately.

Based on California Code of Regulations, Title 22, there were no deficiencies observed during the visit. A copy of the report was provided to the administrator.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021
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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