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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425532
Report Date: 06/17/2021
Date Signed: 09/21/2021 02:25:34 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 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: 5DATE:
06/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Mary Ann HarimisonTIME COMPLETED:
12:32 PM
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Licensing Program Analyst (LPA) Javier Prieto conducted an unannounced annual inspection. LPA met with Mary Ann Harimison, lead staff. The home is licensed for 5 non ambulatory residents, on bedridden with 2 hospice waiver.

The home is a three (3) bedroom, two (2) bath home with a living room, dining room and kitchen. All bedrooms are furnished with bed, night stand, dresser and chair. Bedrooms have adequate lighting for residents’ use. The facility currently has linens, towels and a sufficient amount of hygiene products for residents. The kitchen was observed to have dishes, silverware, pots, and pans. Staff and resident files are locked in the hall closet. The medications are locked in the hall closet as well. The chemicals are locked and kept in a separate hall closet. The backyard was observed to be fully fenced with an unlocked gate and has an umbrella with table and chairs for client’s comfort while sitting outside.

During the visit LPA discussed infection control procedures and practices with Ms Harimison. The home appeared to be in compliance and no deficiencies were observed or cited.

An exit interview was conducted and a copy of this report was reviewed with and provided to Mr.Harrimison
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
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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