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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602870
Report Date: 06/10/2022
Date Signed: 06/10/2022 02:00:29 PM


Document Has Been Signed on 06/10/2022 02:00 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: 52DATE:
06/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Sarah SesayTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices.. LPA met with Facility Administrator and discussed the purpose of today's visit.

This facility consists of: separate dementia unit in the first floor (23 bedrooms), assisted living section has 3 floors (90 bedrooms), recreation area/activity room, dinning area, kitchen, reception/office area, beauty salon, laundry room, IT/Data room and (2) courtyards.

The following were observed/inspected: .
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility and throughout the facility.
  • Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing were observed.
  • PPE supplies observed. Additional PPE supplies are stored inside room 211.
  • Restrooms have hand soap and paper towels. Hand sanitizers observed in common areas throughout this facility..
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed.
  • Per Administrator, (50) residents have both vaccines and 1st booster. (2) residents are not vaccinated and have medical exceptions on file.
  • Per Administrator, there are (70) staff members. 67 staff members have both vaccines and the 1st booster, (1) staff has the 1st vaccine only and (2) staff members are not vaccinated and have religious exceptions on file.


Refer to LIC 809C for the continuation of this report.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022
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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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
VISIT DATE: 06/10/2022
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  • Per Administrator, (11) residents are receiving hospice services.
  • Per Administrator, (8) residents are receiving home health agency services.
  • Per Administrator, (2) residents are bedridden.
  • Medication reviewed for (6) Residents (Resident #1 through Resident #6) and (6) staff files (S-1 through S-6)
  • Staff responsible for direct care and supervision will wear masks.
  • Residents were be socially distanced according to local public health guidelines.
  • Per Administrator, the infection control plan will be submitted to CDSS by 06/30/2022.

Exit interview conducted, a copy of this report and Appeal Rights were provided to Facility Administrator
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022
LIC809 (FAS) - (06/04)
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