197609122-4-29-2022-29-AS-ECAS-CDXUF3-20220429153205

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609122
Report Date: 04/29/2022
Date Signed: 04/29/2022 03:32:52 PM

Document Has Been Signed on 04/29/2022 03:32 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:	04/29/2022
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Editha Lagroza		TIME COMPLETED:	03:40 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 Case Management visit to the facility today with the purpose 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 four (4) residents present during today’s visit. The LPA spoke to the House Manager Robin Aquino over the phone and authorized Editha Lagrosa to sign for the report. During today’s visit, a physical plant tour was conducted at 1:40 p.m. During today’s visit, the LPA observed one (1) new staff at the facility. Staff #1 was on shift and confirmed that they have been working at the facility for about a month. The LPA confirmed that S1 was associated to the facility at the time of the visit. 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. Continued on LIC 9099-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

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: 04/29/2022

NARRATIVE

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On 2/18/22, the facility was cited for failure to provide proof of liability insurance and civil penalties were assessed in the amount of $700 for the period of 2/12/2022 through 2/18/2022. A hard copy of the civil penalty ledger was provided to the licensee.

On 3/23/22, the facility was cited for failure to provide proof of liability insurance and civil penalties were assessed in the amount of $3300 for the period of 2/19/2022 through 3/23/2022. A hard copy of the civil penalty ledger was provided to the licensee.

As of today, 4/29/2022, the plan of correction is still not met. Civil Penalties will be issued for period 3/24/22 - 4/29/22, which is a total of thirty seven (37) 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 Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/29/2022 03:32 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: 04/29/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/29/2022 Section Cited	1 2 3 4 5 6 7	§1569.605 Liability insurance; coverage requirements... all residential care facilities for the elderly...shall maintain liability insurance... in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total... This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	Based on record review, the licensee did not comply with the section cited above as there is insufficient insurance coverage. Which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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 Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

LIC809 (FAS) - (06/04)

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