374604158-3-18-2024-08-AS-MGCO-D3H52Y-20240318193508

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604158
Report Date: 03/18/2024
Date Signed: 03/18/2024 07:36:20 PM

Document Has Been Signed on 03/18/2024 07:36 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:	SERENE RICHVIEW		FACILITY NUMBER:	374604158
ADMINISTRATOR:	CHAN, JEFFREY		FACILITY TYPE:	740
ADDRESS:	1086 CALLE MESITA		TELEPHONE:	(619) 475-4244
CITY:	BONITA	STATE: CA	ZIP CODE:	91902
CAPACITY:	6	CENSUS: 2	DATE:	03/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Caregiver, Chan Jessie		TIME COMPLETED:	02:05 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced Required 1-Year Visit. LPA was greeted by, Caregiver, Jessie Chan to whom she identified herself and discussed the purpose of the visit. All staff present have a current criminal record clearance. During the visit, LPA spoke with Administrator, Jeffrey Chan and explained the reason for the visit. According to the facility’s license, the facility has a maximum capacity of six (6) residents 60 and above of which may be non-ambulatory. During today’s inspection, there were a total of two (2) residents in care. The facility is approved for four (4) hospice waivers. LPA, accompanied by caregiver, Chan, 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. Residents’ bedrooms contained the required furnishings. Doors, windows, 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 resident activities. There were at least 2 days of perishable food, and at least 7 days of 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. The facility had a swimming pool, LPA observed fence height complied with Title 22 regulations, and both gates were locked. Per staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. (Continue at LIC809)

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno	TELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024

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 RICHVIEW	FACILITY NUMBER: 374604158
	VISIT DATE: 03/18/2024

NARRATIVE

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(continue from LIC809)

Fire extinguisher(s) were serviced within the last 12 months. The first aid kit was available and accessible to staff. Required licensing postings were observed in visible areas of the facility. The room temperature in the facility was comfortable at 72 degrees.

LPA interviewed staff and both residents. LPA reviewed multiple staff and both resident records/files. LPA interviews did not raise any licensing concerns. The files that LPA reviewed contained the required documents. Confidential records were stored in locked areas.

During today’s visit, LPA observed via measurement with a thermometer device, that hot water temperature at taps accessible to residents complied with regulations. Water from the kitchen sink reached 120 F and the bathroom sink reached 115 F. No violations were observed during today's visit.

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

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno	TELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024

LIC809 (FAS) - (06/04)

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