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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425532
Report Date: 02/23/2023
Date Signed: 02/23/2023 03:03:26 PM


Document Has Been Signed on 02/23/2023 03:03 PM - It Cannot Be Edited

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: 4DATE:
02/23/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:26 PM
MET WITH:Caregiver-Mary Anne HarmisonTIME COMPLETED:
03:10 PM
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Regional Manager (RM), Reyna Lacey and Licensing Program Manager (LPM), Jazmond Harris conducted a visit to the facility in order to conduct a Health and Safety inspection in order to ensure the facility is operating according to Title 22 regulations. RM and LPM met with Caregiver, Mary Anne Harmison and conducted an inspection of the facility.

The inspection included a tour of the facility inside and outside, to include the staff room. It also included the review of food. This inspection also included discussing with the licensee his behavior on the previous visit. The licensee was reminded to remain professional in his actions with licensing staff.

The following deficiencies were not corrected by the POC due date nor at the time of the visit. Civil Penalties are being assessed and will continue to accrue until correction has been submitted:
Deficiency cited under Title 22 Regulation 87405(d)(5) Administrator - Qualifications and Duties. POC was to no longer do illegal drugs. Licensee was to provide a written statement stating they would no longer allow illegal drug use at the facility and would submit a drug test as proof. The statement was due by 01/19/23. The drug test was to be completed at a doctor's office to confirm it was completed by Licensee Harmison. The licensee was granted an extension until 02/10/23. During today's visit, the licensee confirmed a drug test had not yet been completed. An appointment has been made for 03/06/23. Civil penalties are being assessed for the dates of 02/16/2023 to 02/23/2023 in the amount of $100 per day for 8 days, for a total of $800. Civil penalties will continue to accrue at the rate of $100 a day until corrected.

The licensee was asked to review and sign the report. He requested that the report be reviewed and signed by Mary Ann Harmison. The exit interview was conducted where this report along with the appeal rights, civil penalty assessment, and civil penalty appeal rights were reviewed and provided to caregiver Mary Ann Harmison.
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 248-0341
LICENSING EVALUATOR NAME: Jazmond D HarrisTELEPHONE: (951) 782-4807
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2023
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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