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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602666
Report Date: 01/26/2023
Date Signed: 01/26/2023 05:22:32 PM

Document Has Been Signed on 01/26/2023 05:22 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:APK SERENE, KERNFACILITY NUMBER:
374602666
ADMINISTRATOR:LINDA GRUBBFACILITY TYPE:
735
ADDRESS:19 KERN CTTELEPHONE:
(760) 722-2757
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY: 5CENSUS: 3DATE:
01/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Lead Caregiver Princess Payanga and Administrator Joseph LuevanoTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Lead Caregiver Princess Payanga. LPA then met and discussed the purpose of the visit with Administrator Joseph Luevano, who arrived later during the visit.

Today’s visit was in response to the death of Client #1 (C1 – See LIC811 Confidential Names List for identification of C1), which licensee self-reported to the San Diego CCLD Regional Office. Licensee reported during the early morning of 01-22-2023, staff observed C1 was in bed, but pale and unresponsive. Staff called 911, but paramedics pronounced C1's death at the facility.



LPA briefly toured the facility and attempted to perform a welfare check on the remaining 3 clients in care. However, during LPA's visit, all 3 clients were attending off-site day programs. LPA interviewed staff and obtained copies of pertinent facility records. No deficiencies were identified or cited on this date.

An exit interview was conducted with Luevano, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2023
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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