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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336425532
Report Date: 10/30/2020
Date Signed: 10/30/2020 11:58:05 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/26/2019 and conducted by Evaluator Tricia Danielson
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20191126122046
FACILITY NAME:SERENITY HAVENFACILITY NUMBER:
336425532
ADMINISTRATOR:BRANDON T. HARMISONFACILITY TYPE:
740
ADDRESS:24300 CANYON LAKE DR. NTELEPHONE:
(951) 246-9465
CITY:CANYON LAKESTATE: CAZIP CODE:
92587
CAPACITY:6CENSUS: 4DATE:
10/30/2020
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:MaryAnn Harmison, CaregiverTIME COMPLETED:
11:55 AM
ALLEGATION(S):
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Staff use illegal drugs at the facility.
Staff uses resident's medications.
Staff fail to dispose of medications as required.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tricia Danielson conducted an unannounced complaint televisit to deliver findings on the above complaint category. Due to COVID-19, televisits are being conducted in the place of in-person visits to ensure safety at this time. LPA spoke to Caregiver MaryAnn Harmison and explained the purpose of the call was to deliver findings for this complaint investigation.
Based on LPA observations and interviews, which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC9099D.
These allegations were investigated by the Department. Information was gathered from interviews and a review of medical records obtained. It was revealed that on September 17, 2019 the Licensee/Administrator, Brandon Harmison was admitted to the hospital. While there, Harmison tested positive for Methamphetamines. Harmison also admitted to hospital staff, he used Methamphetamines in the facility. Harmison also admitted to using a deceased hospice resident’s medication for personal use, therefore also
(CONTINUED ON LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 18-AS-20191126122046
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SERENITY HAVEN
FACILITY NUMBER: 336425532
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2020
Section Cited
CCR
87405(d)(5)
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Administrator - Qualifications and Duties: (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (5) Good character and a continuing reputation of personal integrity. This requirement was not met as evidenced by:
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The facility stated they would submit a statement of understanding of the regulation cited by the POC due date of 10/31/2020.
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Based on a review of medical records, it was revealed licensee tested positive for Methamphetamines. Licensee also admitted to hospital staff he used Methamphetamines. This poses an immediate risk to the health and safety of residents in care.
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Type A
10/31/2020
Section Cited
CCR
87405(d)(2)
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Administrator - Qualifications and Duties: (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.This requirement was not met as evidenced by:
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The facility stated they would submit a statement of understanding of the regulation cited by the POC due date of 10/31/2020.
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Based on a review of medical records, licensee admitted to hospital staff he used deceased resident's medication for personal use. This poses an immediate risk to the health and safety of 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: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20191126122046
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SERENITY HAVEN
FACILITY NUMBER: 336425532
VISIT DATE: 10/30/2020
NARRATIVE
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(CONTINUED FROM LIC 9099)
admitting that medications are not disposed of as required. Based on Harmison’s statements and medical records, the licensee failed to show good character and a continuing reputation of personal integrity by using illegal drugs and using medications that were prescribed to residents for personal use.
An exit interview was completed with Caregiver MaryAnn and this signed report was sent via email for a signature along with LIC 9058- Appeal Rights and a read receipt confirms receipt of these documents. Once signed, Caregiver MaryAnn has agreed to send back the report to the Department by the end of the business day.
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20191126122046
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SERENITY HAVEN
FACILITY NUMBER: 336425532
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2020
Section Cited
CCR
87465(i)
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Incidental Medical and Dental-Prescription medications...not taken with...resident upon termination of services, not returned to...pharmacy, shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. This requirement was not met as evidenced by:
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The facility stated they would submit a statement of understanding of the regulation cited by the POC due date of 10/31/2020.
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Based on review of medical records, licensee admitted to hospital staff he used resident’s medication for personal use thereby admitting medications were not disposed of as required. This poses an immediate risk to the health and safety of 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: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 4