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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005552
Report Date: 08/25/2021
Date Signed: 08/25/2021 05:30:50 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: 14DATE:
08/25/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
04:55 PM
MET WITH:Antonieta MedinaTIME COMPLETED:
05:45 PM
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of a health and safety check. LPA met with Staff member (S1) Antonieta Medina and discussed the purpose of the inspection. Administrator (AD) Ray Kuzara was not present during the inspection. During today’s inspection, LPA and S1 observed the following:

LPA and S1 observed there were 2 staff present, wearing PPE. LPA observed 11 residents were present. LPA confirmed residents were doing well and observed no health and safety issues. LPA observed the electricity and water were running and the facility had soap, toilet paper, and paper towels. LPA inspected common areas and kitchen, observed they were clean and organized, and found no health and safety issues. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. LPA observed hallways and walkways were free of obstruction. LPA requested resident roster and staff roster.

There were no health and safety concerns observed in the areas inspected. Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
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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