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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425532
Report Date: 05/23/2022
Date Signed: 05/23/2022 02:20:20 PM


Document Has Been Signed on 05/23/2022 02:20 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:
05/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Staff- Shanta BellTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA), Janira Arreola made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by staff member Maryanne Agco, who was informed of the purpose of the visit. At the time of visit there was 2 staff and 4 residents present. The facility currently has zero positive or suspected Covid-19 cases.

During today's visit, LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings at the facility and advised licensee to post them around the facility. A single entry point was designated where symptoms screenings and temperature checks occur daily for all visitors, residents, and staff. The facility had a plan in place to monitor residents regularly for any changes in condition. The facility had an adequate amount of hand hygiene supplies (soap, hand sanitizer, paper towels) in all restrooms. Common areas such as dining rooms and living rooms have been modified with social distancing and masking policies. There are designated isolation rooms and a plan in place to monitor and attend to those in the isolation rooms. LPA observed a sufficient 30-day supply of PPE equipment. The facility also has a designated infection control lead and a plan in place to clean and disinfect the highly touched surfaces.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2022
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: 05/23/2022
NARRATIVE
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During the tour of the facility LPA and staff noticed the following deficiencies:
· LPA notice (2) pairs of gardening shears available to the residents in the backyard. This poses a potential health and safety risk to residents in care. LPA will issue a Type B deficiency for this.
· LPA observed exposed metal wires and split wood on a gate in the side yard. This poses a potential health and safety risk for residents in care. LPA will issue a Type B deficiency for this.

· A gate was being used to restrict access to the kitchen. There was no waiver or exception on file for this gate. LPA will issue a Type B citation for this.

· LPA observed administrator certificate that was out of date for Administrator Brandon Harmison. Staff member stated that Administrator paid a fine for this being submitted late. LPA will issue a Type B citation for this.

· LPA smelled cigarette and marijuana smoke in the garage and was informed by staff that the Administrator smokes in the garage. R1 is on hospice and LPA observed no smoking signs in the facility and oxygen tank in R1’s room. LPA will issue a type B citation for this.


An exit interview was conducted, and a copy of this report, deficiency pages, and appeal rights were reviewed and provided to facility staff member, Shanta Bell.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/23/2022 02:20 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: 05/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation :
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above with a side gate door in the backyard that had exposed metal wires and split wood. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2022
Plan of Correction
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Licensee will submit photo evidence that this side gate door has been removed. Licensee will correct this by POC date.
Request Denied
Type B
Section Cited
CCR
87618(b)(3)(C)
Oxygen Administration:
(b) In addition to Section 87611(b), the licensee shall be responsible for the following:
(3)Ensuring that the use of oxygen equipment meets the following requirements:
(C)Smoking shall be prohibited where oxygen is in use.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply due to the fact that R1 is on oxygen and there is no smoking signs posted, yet staff stated that Administrator smokes in the garage that is attached to the facility. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2022
Plan of Correction
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Licensee will read and review regulation and submit a written statement stating that the regulation is understood and that the practice will cease at the facility.
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: 05/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 05/23/2022 02:20 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: 05/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87407(a)

"Administrator Recertification Requirements
(a) Administrators shall complete at least forty (40) classroom hours of continuing education during each two (2)-year certification period..."
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above with Administrator certificate for Brandon Harmison being outdates. Staff stated that Administrator was late in renewing the certificate and received a fine.This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2022
Plan of Correction
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Licensee will submit proof of submittion of new administrator certificate and review and read the regulation above. A written statment shall be received stating that the regulation was understood and that the practice will cease at the facility.
Deficiency Dismissed
Type B
Section Cited
CCR
80087(g)
"Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients."

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above with 2 pairs of gardening shears that were accesible in the backyard. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2022
Plan of Correction
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Licensee will submit phot evidence of these items in a secure locked area that is inaccesible to residents.
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: 05/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 05/23/2022 02:20 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: 05/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
80024(a)
"80024 Waivers and Exceptions
(a) Unless prior written licensing agency approval is received as specified in (b) below, all licensees shall maintain continuous compliance with the licensing regulations."

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above due to a gate restricts access to the kitchen passageway. This gate does not have an exception or waiver on file. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2022
Plan of Correction
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Licensee will submit photo proff to LPA that there is unrestricted access to the kitchen by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2022
LIC809 (FAS) - (06/04)
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