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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425532
Report Date: 03/16/2023
Date Signed: 03/16/2023 01:53:27 PM


Document Has Been Signed on 03/16/2023 01:53 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: 3DATE:
03/16/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Shanta Bell, CaregiverTIME COMPLETED:
02:00 PM
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Regional Manager (RM) Reyna Lacey and Licensing Program Analyst (LPA) Tricia Danielson conducted an unannounced case management visit to amend a report that was created on 02/15/2023. RM and LPA identified themselves and discussed the purpose of the visit with Caregiver Shanta Bell.

During the visit, RM explained the amended 809 page and obtained signature on the amended report. An exit interview was conducted with Bell. The amended report and a copy of this report were provided to via hardcopy at the conclusion of the visit.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2023
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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