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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603050
Report Date: 03/18/2022
Date Signed: 03/21/2022 08:10:25 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/15/2022 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20220315162020
FACILITY NAME:VILLA SERRANO CARE HOMEFACILITY NUMBER:
197603050
ADMINISTRATOR:PACITA R. SERRANOFACILITY TYPE:
735
ADDRESS:11937 COHASSET STREETTELEPHONE:
(818) 503-7124
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:6CENSUS: 5DATE:
03/18/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Corazon BaldosTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility has bed bugs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sandra Urena conducted an initial 10-day complaint inspection. The LPA was greeted by staff, and informed staff about the visit. The staff contacted the administrator via phone. The LPA spoke with the administrator and explained the reason for the visit. Administrator stated that they would not be able to be at the facility and instructed the designated staff to sign off on today’s report.

At 12:00 p.m., the LPA and staff conducted a tour of five resident bedrooms and one staff bedroom. At 12:10 p.m., the LPA and staff toured bedroom #2 and the LPA and staff saw evidence of a bedbug infestation.
Regarding the allegation: Facility has bedbugs

Continues on LIC9099...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
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 29-AS-20220315162020
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLA SERRANO CARE HOME
FACILITY NUMBER: 197603050
VISIT DATE: 03/18/2022
NARRATIVE
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The complainant notified the Regional Office to inform them that there is a bed bug situation at the home. It was noted that the facility self-reported the bed bugs issue to the Los Angeles County Regional Center (NLACRC) and that the facility hired a pest control company to fumigate. The facility also self-reported to the licensing agency (Regional Office) about the bedbug infestation on 03/11/2022 and attached a copy of the pest control company inspection report. The fumigation report states that the bedbugs were found in the resident's bedroom #3 and in the couch of the living room. The fumigation company treated these areas, and will be coming back to fumigate on a monthly basis.

Facility records review revealed that this facility reported that there was a presence of bed bugs also identified on 09/29/2021; and, a fumigation of the facility took place in October 2021.

During today’s visit, at approximately 12:00 p.m., the LPA and staff inspected bedrooms 2, 3, 4, 5, 6, and 7. The LPA and staff found evidence of bedbug infestation on the bed linens and on the floor of bedroom # 2.

Based on the investigation, there is sufficient evidence to support the claim that the facility has bedbugs. The administrator took appropriate action when they were observed on 03/11/2022; they immediately notified NLACRC and Community Care Licensing when they were observed and hired a pest control company to handle the situation. However, since they had not noticed or reported this new infestation in bedroom #2, the allegation is deemed as Substantiated at this time.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report was provided, along with appeal rights.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20220315162020
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLA SERRANO CARE HOME
FACILITY NUMBER: 197603050
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/22/2022
Section Cited
CCR
87303(a)
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87303(a) Buildings and Grounds. The facility shall be kept clean, sanitary and in good repair at all times.
This requirement is not met as evidenced by:
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1. Contact Pest Control company to fumigate facility by 03/21/2022. Consult with the pest control company to determine if treatment once monthly is sufficient. Licensee will email the LPA a copy of the invoice of the treatment by 03/22/2022.
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Based on interview, records review, and observation, the licensee did not comply with the section cited above, as the facility was observed to have a new infestation of bed bugs in room #2, which poses a potential health and safety risk to residents 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.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC9099 (FAS) - (06/04)
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