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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425532
Report Date: 02/09/2023
Date Signed: 02/09/2023 10:37:44 AM


Document Has Been Signed on 02/09/2023 10:37 AM - 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:
02/09/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Staff, Mary Anne HarmisonTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Janira Arreola and Javina Geroge conducted an unannounced visit to the facility to conduct a health and safety check. LPAs met with staff, Mary Anne Harmison and informed him of the purpose of the visit.

LPAs conducted a walk through of the facility's interior and exterior. The medications were observed to be locked, and the facility food items were observed to be in required amounts. One resident was observed in the dining room eating and the other (2) residents were in the restroom. The facility's utilities were observed to be in working condition. The facility was observed to be in clean and sanitary condition.

No health and safety issues were observed during the time of the visit.

An exit interview was conducted where this report 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: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2023
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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