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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609122
Report Date: 03/23/2022
Date Signed: 03/23/2022 06:40:45 PM


Document Has Been Signed on 03/23/2022 06:40 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 HEALTHFACILITY NUMBER:
197609122
ADMINISTRATOR:BIOSEH OGBECHIEFACILITY TYPE:
740
ADDRESS:22740 HATTERAS STTELEPHONE:
(818) 312-9121
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: DATE:
03/23/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Editha LagrozaTIME COMPLETED:
04:30 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 (2) staff and five (5) residents present during today’s 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 2:50 p.m. Upon arrival 2:40 p.m. the LPA observed (1) staff who was providing care and supervision to resident, without a face mask. At 2:53 p.m. the LPA observed two (2) moldy cauliflower heads in the kitchen refrigerator. At 2:57 p.m. while the LPA was conducting a temperature check at the kitchen sink, the LPA observed that the water was not going down. When staff was questioned, staff indicated that it was due to the garbage disposal being broken, which had broken down about a week ago. At 3:01 p.m. bathroom #4 was without hand towels.

Cont. 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: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2022
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: 03/23/2022
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 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. On 2/18/22 the facility was cited for failure to correct. As of today 3/23/2022, the plan of correction is still not met. Civil Penalties will be issued for period 2/19/22 - 3/23/22, which is a total of seven (33) 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.

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: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/23/2022 06:40 PM - It Cannot Be Edited

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: 03/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/01/2022
Section Cited

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Personal Rights of Residents in all Facilities (a) Residents in all residential care facilities for the elderly shall have all of the
following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidenced by:
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Based on observation the licensee did not comply with the section cited above as one (1) staff who was providng care and
supervision to residents was observed without a face mask upon arrival which poses an immediate health and safety risk to
persons in care.
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Type B
03/25/2022
Section Cited

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87555(b)(8) General Food Service Requirements(b)The following food service requirements shall apply:(8)All food shall be of good quality.. Food in damaged containers shall not be accepted, used or retained.
This requirement is not met as evidenced by:
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Based on observation, the licensee did not comply with the section cited above, as expired food was observed in the facility kitchen refrigerator, which poses a potential health and safety risk to persons 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: 03/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 03/23/2022 06:40 PM - It Cannot Be Edited

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: 03/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/08/2022
Section Cited

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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
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Based on observation the licensee did not comply with the section cited above as it was observed that the garbage disposal was in disrepair not allowing water to drain which poses a potential health and safety risk to persons 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: 03/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4