197609122-2-18-2022-29-AS-ECAS-CBRVSR-20220218154158

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609122
Report Date: 02/18/2022
Date Signed: 02/18/2022 03:42:33 PM

Document Has Been Signed on 02/18/2022 03:42 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	HANNAH'S HOME BY SERENITY CARE HEALTH		FACILITY NUMBER:	197609122
ADMINISTRATOR:	BIOSEH OGBECHIE		FACILITY TYPE:	740
ADDRESS:	22740 HATTERAS ST		TELEPHONE:	(818) 312-9121
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 4	DATE:	02/18/2022
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Editha Lagrosa		TIME COMPLETED:	03:45 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) Elsie Campos conducted an unannounced Plan of Correction/Case Management (POC) visit to follow up on the Plan of Correction citation issued during the case management visit conducted on 01/28/2022. The LPA was greeted by staff at the time of the visit, there were (2) two staff and (4) four residents present. The LPA spoke with house Manager Robin Aquino over the phone and explained the reason for the visit. 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 1:23 p.m. At 1:38 p.m. the LPA observed oxygen in use in resident bedroom #3. The LPA did not observe the appropriate postings on the bedroom door. The LPA did observe postings on the window of the entrance to the facility. Staff was able to locate oxygen postings and place on resident bedroom door immediately. Technical violation assessed at this time. Continued on LIC 809-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2022

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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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: 02/18/2022

NARRATIVE

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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. On 01/28/2022, the facility was cited for not providing proof of liability insurance. The Proof of Correction was due on, 2/11/2022. As of today 2/18/2022, the plan of correction is not met; civil penalty issued for failure to correct. Civil Penalties will be issued for period 2/12/22 - 2/18/22, which is a total of seven (7) days, at $100.00 per day. At the time of today’s visit the appropriate insurance coverage was not submitted. Civil Penalties will accrue until plan of correction is met.

Exit interview conducted. A copy of the report was issued. Civil penalties and related appeal rights issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2022

LIC809 (FAS) - (06/04)

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