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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609122
Report Date: 01/28/2022
Date Signed: 01/28/2022 07:07:35 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:HANNAH'S HOME BY SERENITY CARE HEALTHFACILITY NUMBER:
197609122
ADMINISTRATOR:BIOSEH OGBECHIEFACILITY TYPE:
740
ADDRESS:22740 HATTERAS STTELEPHONE:
(818) 312-9121
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 4DATE:
01/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Robin Aquino or Lewis, AdministratorTIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elsie Campos conducted an unannounced Case Management visit to the facility today with the purposes of conducting a health and safety check. The LPA met with staff and explained the reason for the visit. There was two staff and four residents present.

On September 8, 2021 the Department accepted the Notice of Defense, resulting in the Default Decision and Order effective October 29, 2021, to be set aside and vacated. The matter raised in the accusation will be heard in an administrative hearing as a part of the due process. On September 9, 2021, the family members of all six residents were informed of the Order Granting Motion to Set Aside and Vacate Default Decision and Order. The administrative hearing process and the possible outcomes were explained to the families. Since the Decision and Order is vacated, the facility will not be closing on October 29, 2021 and new admissions are allowed.
During today’s visit, a physical plant tour was conducted at 3:07 p.m. At 3:12 p.m. the LPA observed the latch on the bathroom sink cabinet had appeared to be locked but the handle was broken, making the items underneath the sink accessible. At 3:12 p.m. the LPA observed that the shower handle was in disrepair. At 3:14 p.m. the LPA observed a side door exit blocked by a stack of iron chairs. When staff was questioned, staff indicated that it was due to a resident who has recently attempted to leave the facility during the night. At 3:41 p.m. the LPA observed that the side door exit was blocked from the inside by a dresser with a television and a bed. At 3:16 p.m. the LPA observed the door to the water heater was off. When staff was questioned, staff indicated that it was due to the water heater being broken. When staff was asked if there was no hot water in the facility, they indicated that there was hot water.

Continued on LIC-809-C
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HANNAH'S HOME BY SERENITY CARE HEALTH
FACILITY NUMBER: 197609122
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/11/2022
Section Cited

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§1569.605 Liability insurance; coverage requirements... all residential care facilities for the elderly...shall maintain liability insurance... in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total...
This requirement is not met as evidenced by:
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Based on record review, the licensee did not comply with the section cited above as there is insufficient insurance coverage. Which poses a potential health and safety risk to residents in care.
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This is a repeat violation. Civil penalty of $250 assesed.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: HANNAH'S HOME BY SERENITY CARE HEALTH
FACILITY NUMBER: 197609122
VISIT DATE: 01/28/2022
NARRATIVE
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Between 3:30 p.m. and 3:38 p.m. the hot water was checked in (4) bathrooms and kitchen sink. It revealed that (2) two out of (4) four bathrooms registered water temperatures at 94.2 degrees Fahrenheit and 95.5 degrees Fahrenheit. (2) two out of (4) four bathrooms registered water temperatures at 151.4 degrees Fahrenheit and 145.5 degrees Fahrenheit. The kitchen sink water temperature registered at 154.7 degrees Fahrenheit.

The facility was initially cited for lack of liability insurance on September 14th, 2021. On November 8, 2021, LPA JoAnn Rosales received a copy of Liability Insurance for this facility. After further review it was indicated that policy #0100165029-0 covers (3) three facilities Hannah's Home by Serenity Care Health, Bentley Suites by Serenity Care Health and Bentley Hills by Serenity Care Health. Therefore, there would be insufficient coverage due to multiple facilities identified under the same policy number. The LPA’s advised the administrator Robin Aquino to obtain sufficient coverage for this facility.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted. Today's report was emailed to house manager Robin Aquino.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HANNAH'S HOME BY SERENITY CARE HEALTH
FACILITY NUMBER: 197609122
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/31/2022
Section Cited

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87303(e)(2) Maintenance and Operation ... Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
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This requirement is not met as evidenced by:
Based on observation the licensee did not comply with the section cited above, as temperature measured out of range which poses an immediate health and safety risk to residents in care.
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This is a repeat violation. Civil penalty of $250 assesed.
Type A
01/31/2022
Section Cited

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87468.1 Personal Rights... Residents in all residential care facilities for the elderly shall have all of the following personal rights:...To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night...
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Based on observation the licensee did not comply with the section cited above, as exit was blocked due to resident wandering which poses an immediate personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4