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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609122
Report Date: 08/17/2021
Date Signed: 09/28/2021 04:18:21 PM

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:
08/17/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Robin AquinoTIME COMPLETED:
02:20 PM
NARRATIVE
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This report is being amended for purposes of correcting a civil penalty issued on the above date, which will be dismissed.

Licensing Program Analyst (LPA) Ashley Smith arrived at the facility unannounced to conduct a Case Management - Other visit. The purpose of the visit is to ensure the Accusation/CDSS No. 6120010302 was posted as required by Law, and to conduct a health and safety check. The LPA met with staff and explained the reason for the visit. The LPA spoke with Administrator Robin Aquino over the phone, whom was unable to be present.

During today's visit, the LPA observed that the accusation was posted on the bulletin board in the hallway. In addition, the LPA spoke with Ms. Aquino over the phone, who confirmed that the residents' responsible parties were notified of the Accusation and were subsequently sent a copy. It was communicated that the residents' responsible party received the Accusation on August 5, 2021.

No deficiencies cited at this time. Exit interview conducted. Ms. Aquino authorized staff to sign the report. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)

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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: 08/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2021
LIC809 (FAS) - (06/04)
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