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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609122
Report Date: 09/14/2021
Date Signed: 09/14/2021 03:13:07 PM


Document Has Been Signed on 09/14/2021 03:13 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: 6DATE:
09/14/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:21 AM
MET WITH:Lewis EllasoTIME COMPLETED:
11:40 AM
NARRATIVE
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Licensing Program Analyst (LPA) KaSandra Lopez made an unannounced Case Management visit to the facility today with the purposes of conducting a health and safety check. The LPA arrived at the facility at 10:21 AM. At the time of the visit, there were two staff and six 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 as well, although the facility is at capacity this time.

At 10:25 AM the LPA began a physical plant tour. At 10:25 AM the LPA observed a knife unsecured with other washed dishes on the kitchen counter. Caregiver Lewis Ellaso said he was drying the dishes and left the knife unattended to answer the door when the LPA arrived. The knife was then secured by Mr. Ellaso. An advisory notice will be issued. At 10:26 AM the LPA observed the keys to the staff room in the door handle. This door leads to the laundry room, office, food, and cleaning supply storage area. Cleaning supplies included; detergent, 409 cleaning spray, bleach, and other cleaning agents. Caregiver Lewis Ellaso stated he left the keys in the door due to doing laundry. The LPA did not observe the washing machine or dryer to be on at this time. The keys were removed from the door and the area was secured. Civil penalties will be assessed as this is the second violation (cited 09/08/21) of the same regulation within a 12 month period.

Report continued on LIC 809-C.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2021
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 3


Document Has Been Signed on 09/14/2021 03:13 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: 09/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/14/2021
Section Cited

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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as.... cleaning supplies and disinfectants.
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, cleaning supplies were accessible to residents with dementia, which poses an immediate health and safety risk to residents in care.
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Request Denied
Type B
09/20/2021
Section Cited

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ยง1569.605 Liability insurance; coverage requirements.... all residential care facilities for the elderly,... shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total....

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This requirement is not met as evidence by:
Based on interview, the licensee did not comply with the section cited above, as the licensee does not have liability insurance which poses a potential health, safety, and person 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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3


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: 09/14/2021
NARRATIVE
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 The LPA spoke with House Manager Robin Aquino at 10:32 AM and explained the reason for the visit. During the phone conversation with Ms. Aquino she said the facility does not have any liability insurance.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted and report issued. During the phone call with Ms. Aquino, the LPA advised the report would be emailed to her by the end of the day.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
LIC809 (FAS) - (06/04)
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