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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425532
Report Date: 06/02/2023
Date Signed: 06/02/2023 05:02:32 PM


Document Has Been Signed on 06/02/2023 05:02 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
RIVERSIDE AC/SC, 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:
06/02/2023
TYPE OF VISIT:Case Management - Health ChecksANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Maryann HarmisonTIME COMPLETED:
05:00 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) Jacqueline Shaw Ross arrived announced to conduct a Health and Safety visit. RM and LPA met with Maryann Harmison, facility staff. Maryann phoned licensee Brandon Harmison during the visit.

There are currently no residents in care. This facility is set to close on June 8, 2023. The RM spoke to the licensee and it was requested to have the facility close effective June 2, 2023. The licensee will provide a written statement requesting the closure and will send it to the Regional Office.

The RM was given the license by Maryann Harmison during today's visit.

An exit interview was conducted with Maryann Harmison, where this report was reviewed. A copy of the report was provided.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw RossTELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
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