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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425532
Report Date: 01/11/2023
Date Signed: 01/11/2023 02:06:05 PM


Document Has Been Signed on 01/11/2023 02:06 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: 3DATE:
01/11/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Staff, Shanta BellTIME COMPLETED:
02:20 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
On 01/11/2023 at 10:30 a.m. Licensing Program Analyst (LPA) Janira Arreola along with Licensing Program Manager (LPM) Joel Esquivel, made an unannounced visit at the facility for the purpose of conducting a health and safety check. LPA Arreola met with, Staff Shanta Bell, and explained the purpose of the visit.

At the time of the visit there was (3) staff and (3) residents present. LPA and LPM conducted a tour of the facilities interior and exterior. LPA walked through back yard, garage, kitchen, living room, and resident bedrooms and bathrooms. The facility has (3) bedrooms and (2) bathrooms. Resident #1 (R1) was in the dining area and Resident #2 (R2) was in their bedroom eating. Resident #3 (R3) was in their bedroom on the phone. (1) rooms is vacant, and (2) rooms are occupied. LPA and LPM observed the licensee, Brandon Harmison in his bedroom with an individual he identified as his caregiver. Licensee refused to identify the staff. Later it was found out the name of this individual as Molly Kuenzi. Ms. Kuenzi had an exempt status and was not cleared or associated to the facility. LPA explained that since the staff was not associated, cleared and had an exempt status, she would have to leave the facility immediately. License stated that he would not comply with the request and would accept any consequences. Facility will be cited for civil penalty of $500. This will be documented along with the plan of correction.

LPA observed the facility's food supply which met the requirements; 2 day supply of perishable and a 7 day supply of non-perishable food items. LPA observed clients medications in locked kitchen cabinet along with refills. LPA collected staff files and resident files during the time of the visit.

LPA and LPM requested to inspect the licensee's room at 12:06 p.m. and were refused by the licensee. When LPA requested to inspect the room licensee stated "no you don't". Licensee stated they will accept a citation for refusal. Facility will be cited for this along with an immediate civil penalty of $500. This will be documented along with the plan of correction.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2023
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 4


Document Has Been Signed on 01/11/2023 02:06 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: 01/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/12/2023
Section Cited

1
2
3
4
5
6
7
87356 Criminal Record Exemption (a) The Department shall notify a licensee to act immediately to terminate... remove...or bar from entering the facility any person described in Sections 87356(a)(1) through (5)...while the Department considers granting or denying an exemption. Upon notification, the licensee shall comply with the notice.
1
2
3
4
5
6
7
The licensee shall remove S1 from the facility immediately, and is not to return to the facility until a valid clearance is obtain. This must be done by POC due date.
8
9
10
11
12
13
14
This requirement was not met as evidenced by: Based on LPA and LPM observation, record review, and interview, it was found that S1 does not have a valid crimal record clearance or exemption. Staff refused to remove S1 from the facility. This poses an immediate personal rights, health or saftey risk to residents in care.
8
9
10
11
12
13
14
Type B
01/20/2023
Section Cited

1
2
3
4
5
6
7
"87412 Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:..." This requirement was not met as evidenced by:
1
2
3
4
5
6
7
The licensee shall obtain the records details in the list provided and shall submit these for for all staff by the POC due date.
8
9
10
11
12
13
14
Based on records review it was found that staff records were missing for (1) staff member. List of missing documents was provuided to staff. This poses a potenital health, saftey or personal rights risk to 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 EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 01/11/2023 02:06 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: 01/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/12/2023
Section Cited

1
2
3
4
5
6
7
"87755 Inspection Authority of the Licensing Agency (a) Any duly authorized officer, employee or agent of the licensing agency may, upon proper identification and upon stating the purpose of his/her visit, enter and inspect the entire premise of any place providing services at any time, with or without advance notice." This requirment was not met as evidenced by:
1
2
3
4
5
6
7
Licensee shall allow licensing staff to inpect all area of the facility upon request. This shall be completed by the POC due date.
8
9
10
11
12
13
14
Based on interview with Licensee, LPA and LPM were refused inspection into licensee's room. This poses an immediate health, saftey or personal rights risk for residents in care.
8
9
10
11
12
13
14
Type B
01/20/2023
Section Cited

1
2
3
4
5
6
7
"87506 Resident Records (b) Each resident’s record shall contain at least the following information:..." This requirment was not met as evidenced by:
1
2
3
4
5
6
7
The licensee shall submit the missing records specified in provided list to the LPA by the POC due date.
8
9
10
11
12
13
14
LPA and LPM went through the facility's records for (1) residents and found that records were missing for the residents that should be on file at the facility. A list of missing documnents was given to staff, LPA spoke with staff Maryanne Harmison who stated they did not have these records.
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 EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


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: 01/11/2023
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
26
27
28
29
30
31
32
LPA and LPM reviewed the client and resident records utilizing the LIC311F and found the following documents were missing. Personnel records were missing for licensee such as; reports of actual hours worked by staff, LIC501, verification of First aid training, and LIC508. Resident records found missing for R1 were LIC613C, and LIC405 and LIC621. A list of missing documents was provided to facility staff. The facility will be cited for not possessing the appropriate records on file, and a plan of correction was documented for this.

An exit interview was conducted, and a copy of this report along with LIC 809-D pages and appeal rights were reviewed and provided to Staff, Shanta Bell.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4