374604074-3-12-2024-08-AS-LSIA-D3APLW-20240312112524

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604074
Report Date: 03/08/2024
Date Signed: 03/12/2024 11:26:30 AM

Document Has Been Signed on 03/12/2024 11:26 AM - 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:	SERENE GREENFIELD MANOR		FACILITY NUMBER:	374604074
ADMINISTRATOR:	CHAN, JEFFREY D		FACILITY TYPE:	740
ADDRESS:	2083 GREENFIELD DRIVE		TELEPHONE:	(619) 444-5731
CITY:	EL CAJON	STATE: CA	ZIP CODE:	92019
CAPACITY:	6	CENSUS: 5	DATE:	03/08/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Caregiver Benjie Chan		TIME COMPLETED:	04:00 PM

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Licensing Program Analysts (LPA) Liliana Silveira conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Caregiver Benjie Chan. The Administrator Jeffrey Chan arrived shortly after.

According to the facility’s license, the facility serves residents age 60 and over and has a maximum capacity of 6 residents. All residents can be non-ambulatory and there is a hospice waiver for 3 residents. During today’s inspection, there were a total of 5 residents in care, and per medical records, all 5 residents were non-ambulatory. This facility does not feature a secured perimeter or delayed egress doors.

LPA, accompanied by Administrator Jeffrey, 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 and screens, 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. The facility’s ambient internal temperature was 70 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, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas.

No pools or bodies of water were observed on the premises. Per Administrator Jeffrey Chan, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. (CONTINUED ON LIC 809C)

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 767-2311
LICENSING EVALUATOR NAME: Liliana Silveira	TELEPHONE: (619) 481-0844
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024

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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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: SERENE GREENFIELD MANOR	FACILITY NUMBER: 374604074
	VISIT DATE: 03/08/2024

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[CONTINUED FROM LIC 809] LPA interviewed staff and residents. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained required documents. Confidential records were stored in locked areas. Jeffrey also presented proof of current/active business liability insurance.

No deficiencies were observed or cited during today's annual inspection.

An exit interview was conducted with Jeffrey, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 767-2311
LICENSING EVALUATOR NAME: Liliana Silveira	TELEPHONE: (619) 481-0844
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024

LIC809 (FAS) - (06/04)

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