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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336425532
Report Date: 06/02/2023
Date Signed: 06/02/2023 05:01:04 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/18/2023 and conducted by Evaluator Jacqueline Shaw Ross
COMPLAINT CONTROL NUMBER: 18-AS-20230518101721
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
ANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Maryann HarmisonTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not administer resident's medication as prescribed.
INVESTIGATION FINDINGS:
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4
5
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7
8
9
10
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12
13
Regional Manager (RM) Reyna Lacey and Licensing Program Analyst (LPA) Jacqueline Shaw Ross arrived announced to deliver findings on the above allegation. RM and LPA met with Maryann Harmison, facility staff. Maryann phoned licensee Brandon Harmison during the visit.

In reference to the allegation of staff did not administer resident's medication as prescribed, the Department conducted interviews and record reviews. The centrally stored log for Resident 1 (R1) dated 04/19/2023, was reviewed and revealed Medication 1 (M1) was filled on 04/18/2023. Facility staff received 5 units and the first date of administration was 04/24/2023. A review of the medication administration record (MAR) for R1 dated 04/18/2023 was reviewed and revealed the medication was administered on 04/24/2023, 04/27/2023 and 04/30/2023. The prescription indicated M1 was to be administered every 72 hours. R1 was discharged from the facility on 05/01/2023. Facility staff interviewed, revealed the new facility R1 transferred to, was given 2 units of M1. Interview with the administrator of the new faciltiy corroborated this information. It was confirmed they received 2 units of M1. Therefore the finding is unfounded. Unfounded means the allegtion is
Unfounded
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 18-AS-20230518101721
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HAVEN
FACILITY NUMBER: 336425532
VISIT DATE: 06/02/2023
NARRATIVE
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is false, could not have happened or is without a reasonable basis. Therefore, the Department has dismissed the complaint.

An exit interview was conducted with Maryann Harmison, after the finding was reported to the licensee, 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
LIC9099 (FAS) - (06/04)
Page: 2 of 2