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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425532
Report Date: 05/11/2023
Date Signed: 05/11/2023 11:41:37 AM


Document Has Been Signed on 05/11/2023 11:41 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: 0DATE:
05/11/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH: Brandon Harmison and Amanda BrooksTIME COMPLETED:
11:44 AM
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Licensing Program Manager (LPM) Joel Esquivel conducted a Health and Safety inspection in order to ensure the facility is operating according to Title 22 regulations. LPM met with Caregiver Amanda Brooks 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.

Harmison also reported the results of his drug test on 4/18/23 had returned; the drug test results dated 4/26/23 shows that Harmison tested positive for Methamphetamine and Amphetamine.

During the visit LPM confirmed that all residents have been relocated. Civil penalties are being assessed for the dates of 04/20/2023 to 04/27/2023 in the amount of $100 per day covering all 8 days, for a total of $800. Civil penalties will continue to accrue at the rate of $100 a day until proof of POC, in it's entirety, is submitted.
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 the licensee Brandon Harmison.
SUPERVISOR'S NAME: Leslie MendivelesTELEPHONE: (951) 782-4137
LICENSING EVALUATOR NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2023
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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