<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425532
Report Date: 03/16/2023
Date Signed: 03/16/2023 01:49:15 PM


Document Has Been Signed on 03/16/2023 01:49 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 - Health ChecksUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Shanta Bell, CaregiverTIME COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Regional Manager (RM) Reyna Lacey and Licensing Program Analyst (LPA) Tricia Danielson 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 LPA met with Caregiver Shanta Bell and explained the purpose of today's visit.
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. The Licensee was to provide a written statement stating he would no longer allow illegal drug use at the facility and would also submit proof of a clean drug test. The statement was due the Regional Office by 01/19/2023. The drug test was to be conducted at a doctor's office to confirm it was completed as required by Licensee Harmison and proof was to be submitted to the Regional Office by 01/25/2023. The Licensee had been granted an extension until 02/10/2023 for completion of the POC. During today's visit, the Licensee reported he had completed the test but did not have results yet. He was also not able to provide proof of having taken the test. Also, the Licensee has not submitted the written statement as required. Civil penalties are being assessed for the dates of 03/02/2023 to 03/16/2023 in the amount of $100 per day covering all 15 days, for a total of $1,500. Civil penalties will continue to accrue at the rate of $100 a day until proof of POC, in it's entirety, is submitted.
Also, during a facility visit conducted on 03/01/2023, it was observed that room #3 had a water leak. The Licensee said he would contact to have a professional come out immediately. RM and LPA verified the leak has been repaired during today's visit.
The Licensee was asked to review and sign this report. He requested that the report be reviewed with and signed by Bell. An exit interview was conducted and this report along with LIC421FC- Civil Penalty Assessment – Failure To Correct And Repeat Violations, and Civil Penalty Appeal Rights were reviewed with and provided to Caregiver Bell.
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)
Page: 1 of 1