197609122-11-22-2021-29-AS-TCAA-C86RDG-20211026125552

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609122
Report Date: 10/26/2021
Date Signed: 11/22/2021 10:47:35 AM

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: 5	DATE:	10/26/2021
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Lewis Ellaso		TIME COMPLETED:	11:45 AM

NARRATIVE

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This is an amended report to correct the amount of issued civil penalties. On 10/26/2021, LPA Teresa Camara conducted an unannounced Plan of Correction/Case Management inspection with purposes of following up on a citation issued during the 9/14/2021 case management inspection, of which the licensee was cited for not having liability insurance. The plan of correction for this citation was due on 09/20/2021. On 09/28/2021, LPA Ashley Morgan conducted a follow up visit and issued civil penalties for the period 09/21/21 through 09/28/21. LPA Morgan advised civil penalties will accrue until plan of correction is met. On 10/12/2021, LPA KaSandra Lopez initially thought that the deficiency was corrected; however, it was later determined that the insurance policy was purchased for three facilities versus one, and the coverage amount would be insufficient. As a result, civil penalties continued to accrue from 09/29/2021 through 10/12/2021. During the visit conducted on 10/26/2021, LPA Camara had insufficient evidence to clear the deficiency, hence civil penalties accrued for the period of 10/13/2021 through 10/26/2021.

On 11/08/2021, LPA Joann Rosales conducted an unannounced Case Management visit. During the visit, the LPA spoke with Donna Luc at Farmers Insurance at 2:44 pm who stated that they will be emailing LPA a copy of the general liability insurance certificate today for the facility which indicates 3 million general aggregate and 1 million per occurrence for the facility. A copy of the revised insurance document was provided, which confirmed that the facility had full coverage.

As a result, civil penalties will end on 10/14/2021, which is the date of issuance of the revised liability insurance document. Total amount of civil penalties assessed will be from 9/21/2021 – 10/14/2021 to the total amount of $2,400. The Department will amend the civil penalties assessed on 9/28/2021, 10/12/2021, and 10/26/2021; as such, the full amount of the civil penalties assessed will be issued today.

Exit interview conducted with Ms. Aquino and the report was signed by Mr. Ellaso. A copy of the report, appeal rights and civil penalty assessment will be emailed to Ms. Aquino.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021

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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