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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602666
Report Date: 09/13/2024
Date Signed: 09/13/2024 12:32:16 PM


Document Has Been Signed on 09/13/2024 12:32 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:LINDA GRUBBFACILITY TYPE:
735
ADDRESS:19 KERN CTTELEPHONE:
(760) 722-2757
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY:5CENSUS: 3DATE:
09/13/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Licensee - Alexa PayladoTIME COMPLETED:
12:30 PM
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An Office visit was held in attendance were Licensee Alexa Paylado Kisner, Administrator Matthew Thacker, Regional Manager’s (RM)s Jerry Romero, Reyna Lacey, Licensing Program Manager (LPM) Tricia Danielson, and Licensing Program Analysts (LPAs) Debbie Palacios and Javina George. During today’s visit the following was discussed:

Discussed the importance of being responsive to Department contact and received updated contact information for the licensee and facility. Licensee reported Matthew Thacker is administrator. Reviewed email sent to Thacker regarding renewal of administrator certificate. Thacker will respond to email with documents sent for renewal and copies of cashed checks to finalize renewal. RM discussed administrator duties regarding providing oversight at all facilities. RO discussed information received from placement agency and the licensee’s plan regarding the information.

Due to the passing of one of the licensees in March of 2024. Licensee was advised to review the by-laws to advise of any needed changes.

Review of gas and electricity were reviewed and was demonstrated these utilities are current. Licensee will provide proof of water bill is current will further be due on same date as below.

Due to the changes that were reported during the meeting the following documents were requested and as discussed are due to the Department no later than close of business day (5pm) on Friday 09/20/24.

1. New lease agreement, 2. LIC309-Administrative Organization, 3.LIC 200-Application, 4. Staff schedule (licensee may use LIC500), 5. Proof of water bill is current.

Licensee was provided copies of forms as well as copies from the public at her request.

An exit interview was conducted with the licensee where this report and forms were reviewed and provided.

SUPERVISOR'S NAME: Icela EstradaTELEPHONE: (619) 688-6866
LICENSING EVALUATOR NAME: Jerry RomeroTELEPHONE: 619-767-2317
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024
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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