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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609122
Report Date: 07/19/2021
Date Signed: 09/28/2021 04:20:20 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:
07/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Robin AquinoTIME COMPLETED:
11:30 AM
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 required annual visit at 9:20 a.m. This annual had a specific emphasis on infection control practices and procedures. In addition, the purpose of the visit is to ensure the Accusation/CDSS No. 6120010302 was posted as required by Law, and that the residents, the residents' responsible parties, and the Local Long-Term Care Ombudsman have all been notified of the Accusation. The accusation was posted today after discussion with the LPA. 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 physical plant was toured. Copies of the resident roster and resident's Identification and Emergency Information were obtained. The Administrator will email the LPA a completed Personnel Report/LIC500. Proof of liability insurance was not obtained; Administrator Robin Aquino explained that they have requested the document from corporate and would send it to the LPA.

KITCHEN: Knives, medication, and disinfectants are kept inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

BEDROOMS: The LPA observed the single-room bedrooms, which were furnished appropriately with clean linens, furnishings and lighting.

RESTROOMS: Restrooms are clean and sanitary with grab bars and non-skid surfaces.

COMMON SPACES: Walls and flooring were checked for cleanliness and good condition.

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

DATE: 07/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021
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 7
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: 07/19/2021
NARRATIVE
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INFECTION CONTROL: The LPA spoke with the Administrator regarding the facility’s infection control practices. The facility has a central entry point for symptom screening, temperature checks, and a sanitation station. The facility has adequate supply of Personal Protection Equipment. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if there is a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate. The LPA recommended the following: post the Department Provider Information Notices (PINs) in an easily accessible location for resident use; continue to check and record temperatures for staff and residents.

Civil penalties will be assessed against any facility that fails to take corrective action within the described time periods. Per the California Health & Safety Code Section 1569.38, you are hereby notified that a $100 civil penalty will be assessed for 07/19/21, of Health & Safety Code Section 1569.38, as requirements are not met. The total civil penalty for each day shall not exceed $100/day regardless of the number of notices the licensee fails to send that day. The total civil penalty for a continuous violation shall not exceed $5,000.

Deficiencies are cited per Health & Safety Code Sections 1569.38 & 1569.605. See 809-D. Exit interview conducted with the Administrator over the phone. The Administrator authorized staff to sign the report. A copy of the report, and appeal rights, were provided.

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

DATE: 07/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021
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: 07/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Other Provisions
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
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: 07/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2021
LIC809 (FAS) - (06/04)
Page: 7 of 7
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: 07/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
1569.605 Liability insurance; coverage requirements On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above, as the facility was unable to relinquish liability insurance, which poses a potential health and safety risk to residents in care.
POC Due Date: 07/23/2021
Plan of Correction
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Licensee has agreed to do the following:
1. Issue a copy of the Liability Insurance by the POC date, 7/23/2021.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: 07/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2021
LIC809 (FAS) - (06/04)
Page: 4 of 7
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: 07/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.38(b)(1)
1569.38(b)(1) Posting of licensing reports; disclosure to new residents. A licensed residential care facility for the elderly shall provide written notice to a resident, the resident’s responsible party, if any, and the local long-term care ombudsman, within 10 days from the occurrence of either of the following events: (1) The department commences proceedings to suspend or revoke the license of the facility pursuant to Section 1569.50.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as the required parties have not received written notice of the accusation, which poses an immediate personal rights risk to residents in care.
POC Due Date: 07/20/2021
Plan of Correction
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Licensee agreed to do the following:
1. Provide written notification of the Accusation to residents, resident’s responsible parties, and the Long Term Care Ombudsman. Submit proof of submission by 7/20/2021.
Type A
Section Cited
HSC
1569.38(e)(1)
1569.38(e)(1) Posting of licensing reports; disclosure to new residents. Upon providing the notice described in subdivision (b), the licensed residential care facility shall also post a written notice, in at least 14-point type, in a conspicuous location in the facility, that may include where the mail boxes are located, where the facility license is posted, or any other easily accessible location in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as the Accusation was not posed in a conspicuous location, which poses an immediate personal rights risk to residents in care.


POC Due Date: 07/19/2021
Plan of Correction
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Licensee agreed to do the following:
This was posted during the visit, 7/19/2021. Plan of Correction met. $100 civil penalty assessed for one day.
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: 07/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2021
LIC809 (FAS) - (06/04)
Page: 2 of 7