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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609122
Report Date: 12/09/2021
Date Signed: 12/09/2021 01:34:37 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: 4DATE:
12/09/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Robin AquinoTIME COMPLETED:
01:10 PM
NARRATIVE
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Licensing Program Analysts (LPA’s) Elsie Campos and Teresa Camara conducted an unannounced Case Management visit to the facility today with the purposes of conducting a health and safety check. The LPA’s met with house manager Robin Aquino and explained the reason for the visit. There was one staff and four residents present.

On September 8, 2021 the Department accepted the Notice of Defense, resulting in the Default Decision and Order effective October 29, 2021, to be set aside and vacated. The matter raised in the accusation will be heard in an administrative hearing as a part of the due process. On September 9, 2021, the family members of all six residents were informed of the Order Granting Motion to Set Aside and Vacate Default Decision and Order. The administrative hearing process and the possible outcomes were explained to the families. Since the Decision and Order is vacated, the facility will not be closing on October 29, 2021 and new admissions are allowed.

During today’s visit, a physical plant tour was conducted at 11:14 a.m. The LPA’s observed at 11:31 a.m. that there was a soiled recliner chair obstructing the exit ramp in the backyard. In addition at 11:32 a.m. the LPA’s observed large nails popping up from the green turf in the backyard.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D)

Exit interview conducted. Today's reports and appeal rights were reviewed and emailed to house manager Robin Aquino.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
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: 12/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/09/2021
Section Cited

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87307(d)(6) Personal Accommodations and Services. The following space and safety provisions shall apply to all facilities: All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
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Based on LPA's observation there was a solid recliner chair obstructing the exit ramp in the backyard, which poses an immediate health and safety risk to residents in care.
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Type A
12/09/2021
Section Cited

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87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:

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Based on the LPA's observation there were large nails popping up from the green turf in the backyard, which poses an immediate health and safety risk to residents in care.
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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: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2021
LIC809 (FAS) - (06/04)
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