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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336425532
Report Date: 11/21/2022
Date Signed: 11/21/2022 05:52:45 PM

Substantiated


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
11/14/2022 and conducted by Evaluator Janira Arreola
COMPLAINT CONTROL NUMBER: 18-AS-20221114133557
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: 4DATE:
11/21/2022
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Licensee Brandon HarmisonTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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The facility is not providing a safe environment for the resident based on resident's condition
Staff yelled at resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Janira Arreola, made an unannounced visit to the facility on 11/21/2022 at 2:15 p.m. in order to close out a complaint investigation. LPA met with Licensee Brandon Harmison, who was informed of the purpose of the visit.

Regarding Allegation #1 “The facility is not providing a safe environment for the resident based on resident's condition“ LPA reviewed Resident 1 (R1)’s written plan of care, as well as medical history on physican’s reports dated 07/29/2022, that R1 has a condition that makes them allergic to certain smells and foods. It was alleged that an incident occurred where the facility failed to provide the resident an environment free of these smells, causing the resident to have an allergic reaction. LPA interviewed staff #2 (S2) who stated that were aware of R1's condition and would ask R1 to leave when these scents where present in the facility. LPA noted that this was not documented on R1's plan of care. LPA observed the facility had frangrance pulg ins that R1 is allergic to. This corroborating the alleged claims that the facility has devices that the resident is allergic to. Therefore based on observation and records review and interviews it was found that the allegation is substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022
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 3
Control Number 18-AS-20221114133557
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
VISIT DATE: 11/21/2022
NARRATIVE
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Regarding allegation #2 “Staff yelled at resident” LPA conducted an interview with the identified staff member, the administrator, in which they stated that they speak loudly and that R1 may have perceived it as yelling, but that they did not yell at R1. LPA interview Staff #2 (S2) who was identified as being at the facility when it was alleged this occurred. S2 stated that they did not hear yelling, but did state the adminstrator and R1 had an argument. LPA attempted interviews with resident but was unable to obtain information pertaining to the allegation due to the residents conditions. LPA reviewed text messages that were sent to R1 from the administrator stating that they were sorry for raising their voice at R1. Based on interviews conducted and records review it was found that the allegation is substantiated.A finding of substantiated means that the preponderance of the evidence standard has been met.


An exit interview was conducted where this report was reviewed and provided to the licensee Brandon Harmison.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20221114133557
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: 11/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/22/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirment was not met as evidenced by:
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The licensee shall create a plan of care that will take into consideration R1's condition and allergies as to keep the resident safe from an allergic reaction. The licensee shall send this to the LPA by the POC due date.
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Based on interviews and records review, and observation, it was found that the facility staff were aware of the residents allegeries and did not create a safe enviornment for R1 to reside in. This is an immediate personal right, health or saftey risk to residents in care.
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Type A
11/22/2022
Section Cited
CCR
87468.1(a)(3)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall...(3)...be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature... This requirment was not met as evidenced by:
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The licensee shall write a self certified letter stating that the section cited has been read and understood. This shall be submitted to the LPA by the POC due date.
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Based on interviews and record review it was foudn that the administrator had admitted to raising her voice at R1. This poses an immediate personal rights, health or saftey risk to the resident in care.
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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: 11/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3