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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604158
Report Date: 06/10/2022
Date Signed: 06/10/2022 04:01:59 PM


Document Has Been Signed on 06/10/2022 04:01 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:SERENE RICHVIEWFACILITY NUMBER:
374604158
ADMINISTRATOR:CHAN, JEFFREYFACILITY TYPE:
740
ADDRESS:1086 CALLE MESITATELEPHONE:
(619) 475-4244
CITY:BONITASTATE: CAZIP CODE:
91902
CAPACITY:6CENSUS: 5DATE:
06/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Caregiver, Benjie ChanTIME COMPLETED:
03:30 PM
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Licensing Program Analyst, (LPA) Marisela Garcia-Centeno, made an unannounced visit to the facility to conduct an annual required licensing inspection. LPA identified herself, and met with Caregiver, Benjie Chan and discussed the purpose of today’s visit. All staff present at the facility have current criminal record clearances.

A tour of the facility was conducted inside and out. LPA conducted a general overall inspection, with specific focus on infection control. In accordance with the Department’s Infection Control program, LPA provided technical assistance and observed and evaluated the facility's implementation of their COVID-19 Mitigation Plan (LIC 808).

During today's inspection LPA observations include the following: Symptom screening procedures for staff, residents and visitors; posted signs regarding visitor policy, promoting hand washing, cough and sneeze etiquette and other infection control procedures; Hand hygiene practices; testing plan and procedures; plans for containing infections, PPE supplies procedures and training; and disinfection procedures.

Based on today’s inspection, no deficiencies were observed at this time in the areas evaluated. This report was discussed with Caregiver, Benjie Chan. A copy of this report along with Licensee Rights (01/2016) was provided to Caregiver, Chan at the conclusion of the exit conference.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022
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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