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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005552
Report Date: 07/19/2021
Date Signed: 07/19/2021 12:44:18 PM

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 HEALTHFACILITY NUMBER:
306005552
ADMINISTRATOR:OGBECHIE, BIOSEHFACILITY TYPE:
740
ADDRESS:317 N RICHMAN AVETELEPHONE:
(714) 213-8248
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY:26CENSUS: 15DATE:
07/19/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Ray KuzaraTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sean Haddad conducted an unannounced case management visit to this facility to ensure the Accusation/CDSS No. 6120010302F was posted as required by Law, and that the residents, the residents' responsible parties, and the Local Long Term Care Ombudsman have all been notified of the Accusation. LPA met with Administrator (AD) Ray Kuzara and explained the reason for today's visit.

During today's visit, the physical plant was toured. Copies of staff/resident rosters and resident's Identification and Emergency Information were obtained. Proof of liability insurance was not obtained.

The Accusation was served to Licensee "Serenity Care Health Corporation" via certified mail on June 16, 2021. The Accusation was not observed posted in a conspicuous location. Licensee did not provide written notification to the residents, their responsible parties, the long term care ombudsman as required. During today's visit, a copy of the Accusation was provided to AD via email and AD printed the copy. AD was instructed to immediately post the Accusation.

LPA attempted to call Administrator/Licensee Bioseh Ogbechie but was unable to speak to Licensee and left a message.

AD stated he was not aware of the Accusation, the posting requirements, or that a written notice must be issued to residents in care, responsible parties, and Local Ombudsman. LPA and AD called Joseph Chen, Executive Director of Assisted Living. Mr. Chen stated he was not aware of the Accusation and was unaware if the Accusation had been received by the licensee.

(See LIC809C for continuation of report)
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021
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 4
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: 07/19/2021
NARRATIVE
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Health & Safety Code Section 1569.38 specifically states that licensee is required to provide written notification to a resident, the residents' responsible party, if any, and the local Long Term Care Ombudsman within 10 days from the date indicated on the Accusation. The licensee is also required to post the Accusation in a conspicuous location, written in at least 14-point type, stating that legal action is being taken against the facility to revoke the license. The 10th day falls June 26, 2021.

Civil penalties will be assessed against any facility that fails to take corrective action within described time
periods. Per California Health & Safety Code Section 1569.38, you are hereby notified that a $100 civil
penalty will be assessed beginning June 27, 2021, if Health & Safety Code Section 1569.38 requirements are
not met. 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.

Civil penalties will accrue until Community Care Licensing has received proof that all required parties have received written notification of the revocation action.

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.

Deficiencies are cited per Health & Safety Code Sections 1569.38 & 1569.605.

LPA spoke to AD and explained citation, civil penalty assessment, and appeal rights.

Exit interview was conducted with AD. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: 07/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/20/2021
Section Cited

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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
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(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.
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Type A
07/20/2021
Section Cited

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POSTING OF LICENSING REPORTS: WRITTEN NOTICE OF REVOCATION. A licensed residential care facility for the elderly shall provide written notice to a resident, the resident’s responsible party, if any, and the... ombudsman, within 10 days from the occurrence of ...: (1) The department commences proceedings
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to suspend or revoke the license of the facility pursuant to Section 1569.50. Accusation posting was not observed in a conspicuous location. Required parties have not been issued a written notice of the Accusation. Facility representatives could not confirm receipt of the Accusation or that all parties have been notified.
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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 StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: 07/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/20/2021
Section Cited

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A licensee who fails to comply with the requirements of subdivision (b) or (c) shall be liable for civil penalties in the amount of one hundred dollars ($100) for each day of the failure to provide notification as required in this section. The total civil penalty for each day shall not exceed one hundred dollars ($100) regardless of the
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number of notices that the licensee fails to send that day. The total civil penalty for a continuous violation of subdivision (b) or (c) shall not exceed five thousand dollars ($5,000). CIVIL PENALTIES are being assessed in the amount of $2,200 for failure to provide notification as required.
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Type B
07/22/2021
Section Cited

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§1569.605 LIABILITY INSURANCE; COVERAGE REQUIREMENTS On and after July 1, 2015, all residential care facilities for the elderly … shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars
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($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. Based on observation and interviews conducted the facility failed to provide proof of liability insurance during the visit.
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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 StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4