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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602870
Report Date: 04/08/2022
Date Signed: 04/08/2022 11:58:11 AM


Document Has Been Signed on 04/08/2022 11:58 AM - 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: 53DATE:
04/08/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:12 AM
MET WITH:Raina Aggawi, Assistant AdministratorTIME COMPLETED:
12:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vasallo conducted a case management visit to issue deficiencies. During an investigation that involved Resident #1 (R1) in March 2021, the department discovered that facility purged R1’s daily log notes. The facility was required to retain R1's records for 3 years. R1 moved out in February 2021.

The deficiency is documented on the 809D.

Exit interview held. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2022
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


Document Has Been Signed on 04/08/2022 11:58 AM - It Cannot Be Edited

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: SERENTO CASA
FACILITY NUMBER: 198602870

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/15/2022
Section Cited

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Resident Records. Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident.
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This deficiency was evidenced by the following:
During an investigation conducted in 2021, the facility was asked to produce R1’s daily logs. Facility could not do so and stated the documents had been “purged”. R1 moved out in February 2021.
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2