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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602666
Report Date: 12/28/2022
Date Signed: 12/28/2022 02:49:59 PM


Document Has Been Signed on 12/28/2022 02:49 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:APK SERENE, KERNFACILITY NUMBER:
374602666
ADMINISTRATOR:LINDA GRUBBFACILITY TYPE:
735
ADDRESS:19 KERN CTTELEPHONE:
(760) 722-2757
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY:5CENSUS: 4DATE:
12/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Caregiver Divinia MatosTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Kayla Hilario conducted an unannounced Case Management visit. LPA identified herself, discussed the purpose of the visit, and met with Caregiver Divinia Matos. The staff present have current criminal record clearance.

The Caregiver Background Check Bureau (CBCB) submitted an Order to Individual of Immediate Exclusion, dated 11/22/2022 for Individual #1 (I1). [See LIC 811 Confidential Names List for a description of I1].

LPA confirmed through records review that I1 is now longer employed at this facility. Both the Administrator Matthrew Thacker and LIcensee Alexa Paylado confirmed that I1 has not worked here in over seven years.

No deficiencies were cited or observed on this date in this regard.

The Licensee was provided a copy of their appeal rights (LIC9058 03/22), and their authorized representative's signature on this form, acknowledges receipt of these rights. An exit interview was conducted with Caregiver Divinia Matos a copy of this report and appeal rights (LIC 9058 03/22) was provided via hardcopy at the conclusion of the visit.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Kayla HilarioTELEPHONE: 619-481-0844
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2022
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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