306005552-7-22-2021-22-AS-SHAD-C56MXZ-20210722100047

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005552
Report Date: 07/22/2021
Date Signed: 07/22/2021 10:00:53 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	KAEGO'S RICHMAN GARDENS BY SERENITY CARE HEALTH		FACILITY NUMBER:	306005552
ADMINISTRATOR:	OGBECHIE, BIOSEH		FACILITY TYPE:	740
ADDRESS:	317 N RICHMAN AVE		TELEPHONE:	(714) 213-8248
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92831
CAPACITY:	26	CENSUS: 14	DATE:	07/22/2021
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	09:13 AM
MET WITH:	Ray Kuzara		TIME COMPLETED:	10:20 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	This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of verifying correction of deficiencies issued during the case management inspection conducted on 07/19/21. LPA met with Administrator (AD) Ray Kuzara and discussed the purpose of the inspection. During today’s inspection, LPA and AD observed the following: Deficiency cited under Health & Safety Code Section 1569.38(g) pertaining to civil penalties for not providing proper notice of the Accusation has not been cleared. The deadline for providing proof of correction was 07/20/21. As of today, proof has still not been received. Per California Health & Safety Code Section 1569.38, continuing civil penalties are being assessed. Civil penalties will accrue until Community Care Licensing has received proof that all required parties have received written notification of the revocation action. The total civil penalty for each day shall not exceed $100/day regardless of the number of notices the licensee fails to send that day. The total civil penalty for a continuous violation shall not exceed $5,000. Deficiency cited under Health & Safety Code Section 1569.38(e) pertaining to posting of the Accusation and notice in a conspicuous location had previously been cleared. However, during today’s inspection, LPA and AD observed the Accusation and notice not posted. AD stated that residents had taken down the Accusation and notice multiple times which required AD to search for and reprint the documents. A deficiency for a repeat violation is being issued and a civil penalty is being assessed. During today’s inspection, AD posted the Accusation and notice at the front entryway at a higher location out of the reach of residents and LPA confirmed. This POC has been cleared. (Page 1)

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: KAEGO'S RICHMAN GARDENS BY SERENITY CARE HEALTH	FACILITY NUMBER: 306005552
	VISIT DATE: 07/22/2021

NARRATIVE

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Deficiency cited under Health & Safety Code Section 1569.38(b)(1) pertaining not providing proper notice of the Accusation has not been cleared. The deadline for providing proof of correction was 07/20/21. As of today, proof has still not been received.

Civil penalties are being assessed. A civil penalty invoice will be received. Payment is due when billed. Payment must be made by a personal, business, or cashier's check or money order made payable to the California Department of Social Services. Please write the facility number and invoice number on your check and include a copy of your invoice with the payment. You will find the invoice number on our invoice. DO NOT SEND CASH.

An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

(Page 2)

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: KAEGO'S RICHMAN GARDENS BY SERENITY CARE HEALTH	FACILITY NUMBER: 306005552
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/22/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/23/2021 Section Cited	1 2 3 4 5 6 7	WRITTEN NOTICE OF REVOCATION. Upon providing the notice described in subdivision (b), the licensed residential care facility shall also post a written notice, in at least 14-point type, in a conspicuous location in the facility... (1) The date of the notice. (2) The name of the residential care facility for the elderly
	8 9 10 11 12 13 14	(3) A statement that a copy of the most recent licensing report ... (4) The name and telephone number of the contact person designated by the Community Care Licensing Division of the department to provide information on the license status of the facility. Based on observation during today's visit the Accusation was not posted in a conspicuous location.	8 9 10 11 12 13 14
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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: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

LIC809 (FAS) - (06/04)

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