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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609122
Report Date: 09/28/2021
Date Signed: 09/28/2021 04:16:18 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:
09/28/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Robin AquinoTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Plan Of Correction / Case Management (POC) visit to follow up on the Plan of Correction citation issued during the case management visit conducted on 09/14/2021 by LPA KaSandra Lopez. The LPA was greeted by staff and at the time of the visit, there were two staff and six residents present. The LPA spoke with House Manager Robin Aquino over the phone and explained the reason for the visit.

On 09/14/2021, the facility was cited for not providing proof of liability insurance. The Proof of Correction was due on, 9/20/2021. As of today, the plan of correction is not met; civil penalty issued for failure to correct. Civil Penalties will be issued for period 9/21/21 - 9/28/21, which is a total of eight (8) days, at $100.00 per day. Civil Penalties will accrue until plan of correction is met.



During today's visit, a physical plant tour was conducted. No health and safety hazards observed.

Exit interview conducted. A copy of the report was issued. Civil penalties and related appeal rights issued.

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

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
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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