374602666-5-26-2023-08-AS-RGAZ-CS82K9-20230526172735

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602666
Report Date: 05/26/2023
Date Signed: 05/26/2023 05:28:15 PM

Document Has Been Signed on 05/26/2023 05:28 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	APK SERENE, KERN		FACILITY NUMBER:	374602666
ADMINISTRATOR:	LINDA GRUBB		FACILITY TYPE:	735
ADDRESS:	19 KERN CT		TELEPHONE:	(760) 722-2757
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92057
CAPACITY: 5		CENSUS: 3	DATE:	05/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Administrator Joseph Luevano		TIME COMPLETED:	05:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Riza Alvarez conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with lead Caregiver Princess Payanga and Caregiver Rudita Yamuta. LPA spoke with Administrator Joseph Luevano on the phone, and he arrived at the facility at 3:00 p.m.

According to the facility’s license, the facility has a maximum capacity of five (5) clients, all of whom are non-ambulatory. During today’s inspection, all three (3) clients are out in the community. The three (3) clients were back from Program at 3:00 p.m.

LPA, accompanied by P Payanga and R Yumuta , toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 111.4 F, bathroom #1 sink was 118.2 F and bathroom #2 sink was 107.3 F.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Riza Gloria Alvarez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: APK SERENE, KERN	FACILITY NUMBER: 374602666
	VISIT DATE: 05/26/2023

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[CONTINUED FROM LIC 809]

No pools or bodies of water on the premises. Per administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Two (2) fire extinguisher(s) were purchased today. LPA was furnished a copy of the receipt. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff and clients and reviewed all client records/files. The client files which LPA reviewed contained required documents. Confidential records were stored in locked areas. The Personal and Incidental records of clients are not present at the facility. Staff files were also not present at the facility. Per Administrator, Licensee had a Title 17 visit last May 19, 2023 and collected all facility files to organize them in the Escondido facility. LPA was able to obtain evidence of 1st Aid training for five (5) out of seven (7) staff in the facility. LPA was also provided with criminal background clearances for five (5) out of seven (7) staff in the facility. LPA was able to check criminical background clearance of the two (2) remaining facility staff. LPA interviews did not raise any licensing concerns.

Deficiencies were observed and cited during today's annual inspection.

An exit interview was conducted with Administrator Luevano to whom a copy of this report, LIC809-Ds and Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.A Plan of Correction was developed with Administrator.

SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Riza Gloria Alvarez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/30/2023 12:34 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 05/30/2023 12:21 PM

Created By: Riza Gloria Alvarez On 05/26/2023 at 05:18 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: APK SERENE, KERN	FACILITY NUMBER: 374602666
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in two (2) out of nine (9) window screens. Two (2) window screens at the living room area had holes. This poses potential health and safety risks to persons in care, employees and visitors.
	POC Due Date: 06/02/2023
	Plan of Correction
1 2 3 4	Licensee will fix the two (2) window screens. Licensee will submit proof of repair to CCL by email - receipts, photos of fixed window screens.

Type B

Section Cited

CCR

80070(a)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interviews, the licensee did not comply with the section cited above, to wit: "(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client." in three (3) out of three (3) clients. The personal and incidental records of clients were not present in the facility. This poses a potential personal rights risk to persons in care.
	POC Due Date: 05/30/2023
	Plan of Correction
1 2 3 4	Licensee will ensure that separate, complete, and current record of clients' personal and incidental records and cash are at the facility at all times. Licensee will submit proof to CCL by email that the missing records/cash are physically at the facility by close of business 05/30/2023.

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:

John Rante

LICENSING EVALUATOR NAME:

Riza Gloria Alvarez

LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

LIC809 (FAS) - (06/04)

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