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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425532
Report Date: 02/03/2023
Date Signed: 02/03/2023 12:02:40 PM


Document Has Been Signed on 02/03/2023 12:02 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
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:
02/03/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Staff, Mary Anne HarmisonTIME COMPLETED:
12:15 PM
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Licensing Program Analysts (LPA) Janira Arreola and Jacqueline Shaw Ross conducted an unannounced visit to the facility on 2/3/2023 at 10:55 am in order to verify corrections of citations issued during a case management visit conducted on January 11, 2023. LPA met with staff Maryanne Harmison, who was informed of the purpose of the visit. At the time of the visit there were (3) staff and (3) residents present.

During the visit a health and safety check was conducted on the facility residents. During the time of the visit LPA conducted a walk through of the facility interior and exterior. LPAs observed the residents, the food supply, the medications, and utilities. No health and safety issues were found during the time of the visit.

The following deficiencies was corrected during today's POC visit:
Deficiency cited under Title 22 Regulation 87356(a) Criminal Record Exemption. POC was to remove Person 1 (P1) from the facility immediately, and not to return to the facility until a valid clearance was obtained. On today's visit the LPAs observed P1 was not at the facility. Interviews with staff and resident confirmed P1 has moved out at the facility on 1/27/2023.

An exit interview was conducted where this report along with the clearance lettwer was reviewed and provided to staff, Mary Anne Harmison.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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