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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609122
Report Date: 11/22/2021
Date Signed: 11/22/2021 10:49:27 AM


Document Has Been Signed on 11/22/2021 10:49 AM - 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:
11/22/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Lewis Ellaso and Editha LagrosaTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Smith 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 Lewis Ellaso and Editha Lagrosa and explained the reason for the visit. There were two staff and five 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 9:40 a.m., the LPA observed that the fire extinguishers were last serviced 11/08/2019. At 9:42 a.m., the LPA observed that the private caregiver bathroom was accessible; as a result, the LPA observed accessible Lysol disinfectant spray, personal hygiene items, razors, and other personal care items. At 9:43 a.m., the LPA observed A+D ointment accessible in Room #3. At 9:44 a.m., the LPA observed accessible A+D ointment in the shared resident restroom. At 9:45 a.m., the LPA observed razors accessible in the shared resident restroom.

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 Ms. Aquino. Ms. Aquino stated that staff Lewis Ellaso is authorized to review and sign reports.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2021
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 2


Document Has Been Signed on 11/22/2021 10:49 AM - 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: 11/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
11/22/2021
Section Cited

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87705(f)(2) Care of Persons with Dementia. 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... cleaning supplies ...
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 cleaning supplies, razors, and ointment were accessible to residents with dementia, which poses an immediate health and safety risk to residents in care.
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Type B
12/06/2021
Section Cited

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87203 Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
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 the fire extinguishers were last serviced 11/8/2019, which poses a potential health and safety 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: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2021
LIC809 (FAS) - (06/04)
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