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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602870
Report Date: 03/18/2022
Date Signed: 03/18/2022 02:23:43 PM


Document Has Been Signed on 03/18/2022 02:23 PM - It Cannot Be Edited

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:SARAH SESAYFACILITY TYPE:
741
ADDRESS:1740 SAN DIMAS AVENUETELEPHONE:
(909) 394-0304
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:131CENSUS: 51DATE:
03/18/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Assistant Administrator, Raina AggawiTIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Vasallo conducted a Case Management - Incident visit to follow-up on an incident report dated 3/14/22. The incident report indicates that Resident #1 (R1) reported to a caregiver that Resident #2 (R2) was being inappropriately touched by a male staff member. R1 did not report the date of the incident and did not have any details.

LPA interviewed R2 during today's visit. R2 indicated that no male staff enter his/her room. R2 reported feeling comfortable in the facility and had no complaints about staff. R1 was interviewed and reported that there were no witnesses to the alleged incident. R1 indicated that he/she didn't know if the incident actually occurred. Law enforcement also visited the facility and spoke with both residents regarding the allegation. Law enforcement did not investigate further. The male staff in question (Staff #1 S1) no longer works for the facility. S1 left for an unrelated issue.

Based on interviews conducted, there were no health and safety concerns found at this time.

Exit interview held. A copy of the report was provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022
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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