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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602666
Report Date: 07/15/2024
Date Signed: 07/15/2024 02:14:34 PM

Document Has Been Signed on 07/15/2024 02:14 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:
07/15/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Staff Rudita YamutaTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Case Management Annual Continuation visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Staff Rudita Yamuta. LPA spoke with Administrator Matthew Thacker via telephone during the visit.

The facility is licensed for a maximum capacity of 5 non-ambulatory clients. During today’s visit, the facility had a census of 3 clients, all of which were ambulatory. The Administrator for the facility is Matthew Thacker and their certificate is pending.

During visits on 5/20/24, 6/25/24, and today, LPA toured the facility and inspected each room of the facility, including client rooms, bathrooms for client and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed on the premises. LPA did not observe any aspects of delayed egress or secured perimeter. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 108.7 degrees Fahrenheit in a common bathroom. The facility’s internal temperature was measured at 72 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Princess Payanga, no firearms or weapons are stored on the premises. LPA also observed locked storage for client medications and client and staff files. Client medications are stored in their original container and labelled. LPA observed a minimum of a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator was kept at 40 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit. LPA observed linens and hygiene products provided to the clients that are in good repair and sufficient to meet their needs. Staff present at the facility during the time of the inspection had a criminal background clearance and were associated to the facility.

Continued on LIC809-C page…
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2024
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: APK SERENE, KERN
FACILITY NUMBER: 374602666
VISIT DATE: 07/15/2024
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LPA reviewed multiple client and staff records. Each client record was complete and contained a signed admission agreement, updated physician’s report and medical assessment, documents regarding safeguarding personal property and cash resources, and personal rights. Each staff file was complete and contained a personnel record, fingerprint clearance and association, and a health screening. LPA spoke with staff and clients present at the facility during the time of the inspection and those interviews did not reveal any licensing or regulatory concerns.

The Administrator will submit copies of the LIC500 Personnel Report and LIC610E Disaster Plan to the Department within 15 business days.

No deficiencies were cited on today's date. An exit interview was conducted with Caregiver Rudita Yamuta, 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: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024
LIC809 (FAS) - (06/04)
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