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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609122
Report Date: 11/08/2021
Date Signed: 11/08/2021 04:28:45 PM


Document Has Been Signed on 11/08/2021 04:28 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: 5DATE:
11/08/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:08 AM
MET WITH:Lewis EllasoTIME COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) JoAnn Rosales conducted an unannounced Case Management visit to the facility today with the purposes of conducting a health and safety check. LPA met with staff Lewis Ellaso. LPA spoke with House Manager Robin Aquino over the phone and explained the reason for the visit. House Manager stated that staff Ellaso is authorized to review and sign reports.

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. During facility tour at 11:26 am with staff Ellaso LPA observed full bed rails on resident #1 (R1)'s bed, total body cleanser, skin protectant ointment, lavender fragranced warming oil in R1's room accessible to residents. During facility tour at 11:29 am with staff Ellaso LPA observed full bed rails on R2's bed, body lotion, vitamins A&D ointment, toothpaste, total body cleanser, shampoo & body wash in R2's room accessible to residents. During facility tour at 11:32 am with staff Ellaso LPA observed body wash in resident bathroom accessible to residents. During facility tour starting at 11:40 am LPA observed half bed rails on R3's and R4's bed. During facility tour at 11:43 am with staff Ellaso LPA observed hot water temperature at 100.8 degrees F. in resident bathroom. During facility tour at starting 11:55 am with staff Ellaso LPA observed prescription 600 mg ibuprofen tablets in an open purse, engine oil,

Continued on 809-C

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2021
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 5


Document Has Been Signed on 11/08/2021 04:28 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: 11/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/09/2021
Section Cited

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87705 Care of Persons with Dementia(f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
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Based on LPA's observations and record review, the licensee did not comply with the section cited above as over the counter medication and toxic substances were observed accessible to residents which posed an immediate health risk to persons in care.
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Request Denied
Type A
11/09/2021
Section Cited

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87309 Storage Space. (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
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Based on LPA’s observations, the licensee failed to ensure that prescription medication was stored inaccessible to residents which posed an immediate health 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 11/08/2021 04:28 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: 11/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
11/15/2021
Section Cited

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87608 Postural Supports. (a)(5)(B) Postural Supports. Under no circumstances shall postural supports... Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
This requirement is not met as evidenced by:
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Based on LPA’s observations and record review, the licensee did not comply with the section cited above as R1 and R2’s hospice care plans do not specify the need for full bed rails which poses a potential safety risk to persons in care.
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Deficiency Dismissed
Type B
11/15/2021
Section Cited

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87608 Postural Supports.(a)(5)(A) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.
This requirement is not met as evidenced by:
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Based on LPA’s observations and record review, the licensee failed to ensure that they have a physician’s order for R3 and R4’s half bed rails which poses a potential 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 11/08/2021 04:28 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: 11/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
11/15/2021
Section Cited

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87303 Maintenance and Operation. (e)(2)Water supplies and plumbing fixtures shall be maintained as follows: Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature…
This requirement is not met as evidenced by:
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Based on LPA's observations the licensee did not comply with the section cited above as the water temperature tested at 100.8 degrees F which poses a potential health 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5


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: 11/08/2021
NARRATIVE
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grout, polyurethane, ceramic tile adhesive, grout and tile sealer, interior latex primer in unlocked outside storage area. During a review of 2 of 5 resident records starting at 12:43 pm LPA observed that R1 and R2 do not have an order for full bed rails as part of their hospice care plans. LPA observed that R3 and R4 do not have a physicians orders for half bed rails.

LPA spoke with Donna Luc at Farmers Insurance at 2:44 pm who stated that they will be emailing LPA a copy of the general liability insurance certificate today for the facility which indicates 3 million general aggregate and 1 million per occurrence for the facility.

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. Today's reports and appeal rights were reviewed and emailed to the House Manager.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5