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Department of
SOCIAL SERVICES
Community Care Licensing
COMPLAINT INVESTIGATION REPORT
Facility Number:
197603050
Report Date:
03/18/2022
Date Signed:
04/13/2022 10:44:44 AM
Unsubstantiated
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
11/15/2021
and conducted by Evaluator
Sandra Urena
COMPLAINT CONTROL NUMBER:
29-AS-20211115153411
FACILITY NAME:
VILLA SERRANO CARE HOME
FACILITY NUMBER:
197603050
ADMINISTRATOR:
PACITA R. SERRANO
FACILITY TYPE:
735
ADDRESS:
11937 COHASSET STREET
TELEPHONE:
(818) 503-7124
CITY:
NORTH HOLLYWOOD
STATE:
CA
ZIP CODE:
91605
CAPACITY:
6
CENSUS:
5
DATE:
03/18/2022
UNANNOUNCED
TIME BEGAN:
10:00 AM
MET WITH:
Corazon Baldos
TIME COMPLETED:
03:40 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Unexplained death.
Facility did not seek resident timely emergency medical attention.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
This an amended report. Please refer to the reports issued on 4/12/2022.
Unsubstantiated
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
4
Control Number
29-AS-20211115153411
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
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
This is an amended report, please see report issued on 4/12/2022.
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
4
Control Number
29-AS-20211115153411
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
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
This is an amended report, please see report issued on 4/12/2022.
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:
3
of
4
Control Number
29-AS-20211115153411
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
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
This is an amended report, please report issued on 4/12/2022.
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:
4
of
4