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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425532
Report Date: 11/21/2022
Date Signed: 11/21/2022 06:00:06 PM


Document Has Been Signed on 11/21/2022 06:00 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:
11/21/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Licensee Brandon HarmisonTIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola, made an unannounced visit to the facility on 11/21/2022 at 2:15 p.m. in order to cite deficiencies observed. LPA met with Licensee Brandon Harmison, who was informed of the purpose of the visit. At the time of the visit there were (2) staff and (4) residents present.

LPA conducted a visit on 11/18/2022 and observed the following deficiencies:

  • ·LPA conducted a tour of the facility garage. Before opening the door, Staff 1 (S1), accompanying LPA on facility tour, stated “ no one lives in the garage”. LPA observed there was a mattress on a bedframe, with linens and a pillow in the garage close to the exit door on the left side. LPA took a photo of this bed. LPA observed (2) individuals (I1 and I2) standing next to this bed in the garage, who were not listed as residents nor staff. LPA spoke with (I1) who stated they were visitors. The facility sketch was reviewed and it was found that the bed observed was not in a designated living area. LPA spoke to licensee on 11/21/2022 who stated Therefore, based on interviews, observation, and record review, it was found that the facility is in violation of CCR Title 22 Division 6 Chapter 8 Article 05. Physical Environments and Accommodations Section 87307(a)(2)(B). An LIC809-D page was documented along with the plan of correction.
  • ·LPA found (2) individuals in the facility garage. Both of these individuals were not within the age range of the population served by the facility. Additionally, LPA reviewed the Guardian Roster and did not find them listed there. (I1) stated that they were a vistor of the licensee. The facility has been previously cited on 03/02/2020 for staff sleeping in the facility living room and 6/17/2021 for having individuals living in the facility shed that were not finger print cleared. Based on observation of these individuals being next to a bed in the facility garage, facility history, and record review of the Guardian Roster the LPA will be citing for uncleared individuals in the home. CCR Title 22 Division 6 Chapter 8 Article 6 Background Check Section 87335(e)(1). LIC809-D was documented along with the plan of correction.

An exit interview was conducted where this report along with LIC809-D page and appeal rights were reviewed and provided to Licensee Brandon Harmison
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2022
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 2


Document Has Been Signed on 11/21/2022 06:00 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/22/2022
Section Cited

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“87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department…” This requirement was not met as evidenced by:
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Based on interview, record review, and observation, the facility has (2) individuals residing in the home that are not fingerprint cleared. This an immediate health, safety, or personal rights risk to residents in care.
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Type B
12/01/2022
Section Cited

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“87307 Personal Accommodations and Services (a) Living accommodation... The facility shall…provide…living accommodations and privacy for the residents, staff, and others who may reside in the facility… (2) Resident bedrooms shall be provided..:(B) No room commonly...
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...used for other purposes shall be used as a sleeping room for any resident.
This includes… garage storage area…” This requirement is not met as evidenced by: It was found that a bed was located in the facility garage, this is not a designated living area listed on the facility sketch.garage.S1 stated that “no one lives in the garage”...
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The licensee shall remove this bed from the garage and send a self certified letter, signed by the licensee stating that the regulation cited has been read and understood. This shall be sent to the LPA by the POC due date, along with a photo of the garage showing this bed has been removed.
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 EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2022
LIC809 (FAS) - (06/04)
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