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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425532
Report Date: 01/18/2023
Date Signed: 01/18/2023 11:14:54 AM

Document Has Been Signed on 01/18/2023 11:14 AM - 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: 3DATE:
01/18/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Licensee and Administrator, Brandon HarmisonTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Janira Arreola and Regional Manager (RM) Reyna Lacey conducted an unannounced visit to the facility in order to verify corrections of citations issued during a case management visit conducted on January 11, 2023. LPA met with staff Maryanne Harmison who was informed of the purpose of the visit. At the time of the visit there were (2) staff and (3) residents present.

The following deficiency was corrected during today's POC visit:
Deficiency cited under Title 22 Regulation 87755(a) Inspection Authority of the Licensing Agrency . POC was to allow the department staff to inspect all areas of the facility upon request. Deficiency has been cleared as during this visit the licensee granted the LPA and RM inspection of the facility to include the shed, garage, and staff room.

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 87356(a) Criminal Record Exemption. POC was to remove Person 1 (P1) from the facility immediately, and not to return to the facility until a valid clearance was obtained. On today's visit the LPA and RM observed P1 was still at the facility. Interviews conducted revealed P1 is still residing at the facility. Civil penalties are being assessed for the dates of 1/13/2023 to 1/18/2023 in the amount of $100 per day for 6 days. Civil penalties will continue to accrue at the rate of $100 a day until P1 is removed from the facility.

During today's visit, LPA and RM observed cameras located in common areas: living room and dining room. LPA and RM spoke with the Licensee who requested that the LPA and RM speak to Staff 1 (S1) regarding the cameras. S1 reported that a revised plan of operation was not submitted. Nor do they have signed consent forms or updated admission agreements informing residents and their responsible parties of the cameras.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/18/2023
NARRATIVE
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The facility staff report the cameras do not possess audio recording abilities. A deficiency will be cited on the LIC809D page.

Licensee refused to participate in the exit interview and refused to sign the report. An exit interview was conducted where this report along with deficiency pages, and appeal rights were reviewed with staff, Maryann Harmison.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/18/2023 11:14 AM - It Cannot Be Edited


Created By: Janira Arreola On 01/18/2023 at 09:44 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SERENITY HAVEN
FACILITY NUMBER: 336425532

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/25/2023
Section Cited

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons." This requirment was not met as evidenced by:
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Based on observed and interview it was found that the facility has operating cameras in common area of dining and living rooms. The licensee does not have consent of residents via consent forms, plan of operation and admission agreement. This poses a potenital health, safety, or personal rights risk for 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:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2023


LIC809 (FAS) - (06/04)
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