336425532-6-17-2021-18-AS-KCLS-CV6LN3-20230829085336

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336425532
Report Date: 06/17/2021
Date Signed: 06/17/2021 01:12:33 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/06/2021 and conducted by Evaluator Javier Prieto

COMPLAINT CONTROL NUMBER: 18-AS-20210506110318

FACILITY NAME:	SERENITY HAVEN		FACILITY NUMBER:	336425532
ADMINISTRATOR:	BRANDON T. HARMISON		FACILITY TYPE:	740
ADDRESS:	24300 CANYON LAKE DR. N		TELEPHONE:	(951) 246-9465
CITY:	CANYON LAKE	STATE: CA	ZIP CODE:	92587
CAPACITY:	6	CENSUS:	DATE:	06/17/2021
		UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Marie Ann Harimison		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Residents were left out in the sun for an extended period of time.

Facility is odoriferous.

Residents are not being adequately supervised.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Javier Prieto arrived at the facility to conclude a complaint investigation regarding allegations that residents were left out in the sun for an extended period of time, facility is odoriferous, and residents are not being adequately supervised. LPA Prieto met with lead satff Marie Anne Harimison who toured facility and interviewed five residents (R1, R2, R3, R4 and R5). There was no statements made by residents that they are not adequately supervised or that they are left out in the sun for extended periods of time. LPA observation noted home was cool and free from odors.

Based on the information obtained there is not enough evidence that residents were left out in the sun for an extended period of time, facility is odoriferous, and residents are not being adequately supervised. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

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 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/06/2021 and conducted by Evaluator Javier Prieto

COMPLAINT CONTROL NUMBER: 18-AS-20210506110318

FACILITY NAME:	SERENITY HAVEN		FACILITY NUMBER:	336425532
ADMINISTRATOR:	BRANDON T. HARMISON		FACILITY TYPE:	740
ADDRESS:	24300 CANYON LAKE DR. N		TELEPHONE:	(951) 246-9465
CITY:	CANYON LAKE	STATE: CA	ZIP CODE:	92587
CAPACITY:	6	CENSUS:	DATE:	06/17/2021
		UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Mary Ann Harimison		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility does not provide a safe environment for residents.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Javier Prieto arrived at the facility to conclude a complaint investigation regarding allegations that facility does not provide a safe environment for residents. LPA Prieto met with lead staff Mary Anne Harimison who reported that on March 19, 2021, a fire occurred in the back yard of the facility where the fire department was called and fire extinguished. The fire was a sofa near a shed approximately 6 yards from the main home. During time of fire, there were one (1) male and one (1) female adult that were later found to not be fingerprint cleared and living in the shed. Administrator did not report the fire to Licensing. No damage was caused to the main home. Administrator stated to LPA that they were aware of the fire, uncleared adults living in the shed and did not report this to Licensing until LPA asked for a summary of events at time of complaint visit.
Based on LPA observations, interviews which were conducted and records review, the preponderance of evidence standard has been met. Therefore the above allegation(s) is/are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division & Chapter number) are being cited on the attached LIC 9099D).

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 18-AS-20210506110318

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/17/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/17/2021 Section Cited CCR 87468(a)(2)	1 2 3 4 5 6 7	87468 Personal Rights (a) Residents in a residential care facilities to the elderly shall have personal rights. This requirement was not met evidenced by:	1 2 3 4 5 6 7	Administrator to immediate conduct in service training on caring to residents in home.
	8 9 10 11 12 13 14	Based on observations and interviews, it was revealed that a fire occured in the backyard of the facility at close proximity to the home. Two adults were present during the time of the fire that were not fingerprint cleared or associated to the facilty, which posed an immediate health and safey risk to the residents in care	8 9 10 11 12 13 14	Administrator was made aware the civil penalties will be assessed at this time.
Type A 06/17/2021 Section Cited CCR 87411(g)(1)	1 2 3 4 5 6 7	87411 (g) (1) Personnel Requirements - General Prior to employment or intial presence in facility all employees and volunteers subject to a criminal record review shall obtain a clearance.	1 2 3 4 5 6 7	Administrator to immediate remove uncleared adults and not allow re-entry to the facility without being fingerprint cleared and associated to the facility.
	8 9 10 11 12 13 14	Based on observations and interviews, it was revealed that a fire occured in the backyard of the facility at close proximity to the home. Two adults were present during the time of the fire that were not fingerprint cleared or associated to the facilty, which posed an immediate health and safey risk to the residents in care	8 9 10 11 12 13 14

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 Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 18-AS-20210506110318

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/17/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/17/2021 Section Cited CCR 87211(a)(3)	1 2 3 4 5 6 7	87211 (a) (3) Reporting Requirements - Each licensee shall furnish to the licensing agency such reports as the Department may require, including but not limited to fires in on the premises shall be immediately to local fire authority and licensing the next working day. This requirement was not met evidenced by:	1 2 3 4 5 6 7	Administrator to provided immediate in service training on reporting requirement to all staff associated to the facility.
	8 9 10 11 12 13 14	Based on interviews, administrator had a fire on facility property on March 19, 2021, fire department was called and administrator stated to LPA that report was not sent to Licensing regarding the fire, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	In service training is due to Licensing by the end of business day 06/17/2021
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4