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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602666
Report Date: 10/22/2024
Date Signed: 10/22/2024 05:19:19 PM

Document Has Been Signed on 10/22/2024 05:19 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:APK SERENE, KERNFACILITY NUMBER:
374602666
ADMINISTRATOR/
DIRECTOR:		LINDA GRUBBFACILITY TYPE:
735
ADDRESS:19 KERN CTTELEPHONE:
(760) 722-2757
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY: 5CENSUS: 3DATE:
10/22/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:Caregiver Princess PayangaTIME VISIT/
INSPECTION COMPLETED:
05:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Caregiver Princess Payanga.

During today’s visit, LPA conducted a health and safety check, observed clients in care, reviewed facility records, and interviewed staff. During the visit, it was determined that the facility does not have a working land-line for client use or in case of emergencies. LPA Ruiz attempted to call the facility's listed telephone number and discovered that the phone number had been changed. Interviews revealed that staff use their personal cell phones in case of emergency, but there is no dedicated cell phone or working land line present at the facility at all times for staff or client use, or in case of an emergency.

The following deficiency for accessible telephone is cited per California Code of Regulations and noted on the attached LIC809-D page.

An exit interview was conducted with Caregiver Princess Payanga, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2024
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 10/22/2024 05:19 PM - It Cannot Be Edited


Created By: Rebecca A Ruiz On 10/22/2024 at 04:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: APK SERENE, KERN
FACILITY NUMBER: 374602666

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/29/2024
Section Cited
CCR
80073(a)

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80073 Telephones (a) All facilities shall have telephone service on the premises.

This requirement has not been met as evidenced by:
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Administrator will locate the cell phone designated for facility use and will transfer the SIM card to that cell phone. Administrator will provide LPA with the new phone number and conduct an in-service training for staff on the new cell phone use. Administrator will provide the phone number and staff sig in in sheet
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Based on interviews and observation, the Licensee did not ensure that the facility had a dedicated phone that was in working order and present at the facility at all times. This poses a potential safety risk to 3 of 3 clients in care.
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to the Department by POC due date of 10/29/2024.

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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:Jennifer Lott
LICENSING EVALUATOR NAME:Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024


LIC809 (FAS) - (06/04)
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