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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603050
Report Date: 04/10/2025
Date Signed: 04/10/2025 02:50:40 PM

Document Has Been Signed on 04/10/2025 02:50 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:VILLA SERRANO CARE HOMEFACILITY NUMBER:
197603050
ADMINISTRATOR/
DIRECTOR:		PACITA R. SERRANOFACILITY TYPE:
735
ADDRESS:11937 COHASSET STREETTELEPHONE:
(818) 503-7124
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 4DATE:
04/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:34 AM
MET WITH:Jheria FrazierTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:34 AM. LPA met with facility staff who contacted the Administrator Jheria Frazier via telephone call. The Administrator arrived to the facility at approximately 11:00 AM Entrance interview conducted and the reason for the visit was explained.

Beginning at 09:40 AM, the LPA, along with staff #1 (S1) toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

COMMON AREAS: This includes the living room, dining area/entryway, and hallway. LPA observed the living room to be clean and properly furnished at the time of the visit. LPA observed the living room to contain a couch, a television, and a locked medication closet. Additionally, the living room contained a closet that contained the facility’s washer and dryer. The dining area/entryway was observed to be clean and contains adequate seating for resident use. The hallway was observed to contain three (3) closets that contained linens and care supplies. LPA observed one window screen in the hallway to contain a large rip in the screening material. Smoke detectors and carbon monoxide detectors were tested at 10:09 AM and were functional at the time of the visit. All common areas of the facility contained cameras. LPA confirmed with the Administrator that the cameras are non-functional and audio is not recorded.

Continued on LIC 809C.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLA SERRANO CARE HOME
FACILITY NUMBER: 197603050
VISIT DATE: 04/10/2025
NARRATIVE
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BEDROOMS: There are six (6) bedrooms in the facility; three (3) are designated for resident use and three (3) are designated as staff rooms. Two (2) resident bedrooms are single occupancy rooms and one (1) resident bedroom is a dual occupancy room. LPA and S1 toured all three (3) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, emergency flashlights, and sufficient lighting. All three (3) staff rooms were observed to be locked and inaccessible to clients in care. While observing one (1) resident’s bedroom LPA observed a paper that read, “Don’t Listen $5.00, Trash $1.00, Don’t Share $5.00, Dirty Poopi Clothes $5.00, Dirty Pampers $5.00.” LPA asked S1 to explain why this paper was in the resident’s room. S1 stated that the resident has an issue with maintaining hygiene and penalties are subtracted from their lunch money if they violate rules. S1 stated that the paper is there to scare the client in to not violating those policies. The Administrator clarified that the resident has a McDonalds gift card that the facility loads money on to and the facility does not confiscate the resident’s PNI money. LPA informed S1 and the Administrator that exercising penalties on the clients cash resources and placing a sign in the resident’s room to scare them into compliance is a violation of the resident’s personal rights. Both S1 and the Administrator expressed understanding and agreed to remove the sign and not impose penalties on the resident.

BATHROOMS: There are three (3) bathrooms at the facility. One (1) is designated as a common resident bathroom and two (2) are designated as a staff bathrooms. The resident bathroom was observed to be relatively clean and in good repair and was equipped with nonskid surfaces. The water temperature was measured in the resident bathroom to be 105.8 degrees Fahrenheit which is in compliance with regulation.

KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed the pantry to be secured and contained knives and other sharp objects. The LPA observed a fire extinguisher to be fully charged and recently purchased.



OUTDOOR SPACE: The facility has three (3) emergency exit gates, One (1) in the front yard and two (2) on either side of the home. LPA observed two plastic chairs to be blocking the front emergency exit gate. Facility staff agreed to remove the chairs at the time of the visit. The facility has adequate shaded outdoor seating for resident use. LPA observed three (3) appropriately secured sheds. Continued on LIC 809C.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLA SERRANO CARE HOME
FACILITY NUMBER: 197603050
VISIT DATE: 04/10/2025
NARRATIVE
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RECORD REVIEW: Record review began at 11:10 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Four (4) staff files were reviewed. Four (4) staff files did not contain completed medical assessments, and two (2) staff files did not contain Tuberculosis (TB) tests. Four (4) resident files were reviewed. All resident files contained all required documentation and signatures.

MEDICATION REVIEW / CASH RESOURCE REVIEW: Medication review began at 12:22 PM. Medications are stored centrally and securely in a locked closet in the living room. Medications for two (2) residents were observed. All medications reviewed were documented properly on their centrally stored medication and destruction record sheet. No deficiencies were observed during medication review. Cash resource review began at 01:55 PM. Cash resources were reviewed for two (2) residents. All cash resources were stored properly and were accompanied by all corresponding receipts. No deficiencies were observed during medication or cash resource review.

INFECTION CONTROL / EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the
facility's infection control plan and the facility’s emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 02/20/2025. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s administrator.

INTERVIEWS: LPA interviewed one (1) staff member. The staff member interviewed was knowledgeable on their role and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse. LPA was unable to conduct client interviews during the inspection as all clients were out of the facility at the time the inspection was conducted.

During today’s visit LPA obtained a copy of the facility’s updated LIC500 and liability insurance. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/10/2025 02:50 PM - It Cannot Be Edited


Created By: Trevor Byrne On 04/10/2025 at 02:11 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLA SERRANO CARE HOME
FACILITY NUMBER: 197603050

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the pathway to the front emergency exit was blocked by two plastic chairs which poses a potential safety risk to persons in care.
POC Due Date: 04/10/2025
Plan of Correction
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Facility staff removed the chairs at the time of the visit and agreed to not block the path in the future. POC cleared.
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as one window screen was observed to be in disrepair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2025
Plan of Correction
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Licensee will submit proof of completed repairs to CCLD no later than POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/10/2025 02:50 PM - It Cannot Be Edited


Created By: Trevor Byrne On 04/10/2025 at 02:11 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLA SERRANO CARE HOME
FACILITY NUMBER: 197603050

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as 4 employees did not have completed health screenings and 2 employees did not have TB tests which poses a potential health risk to persons in care.
POC Due Date: 04/24/2025
Plan of Correction
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Licensee will send proof of completed health screenings and TB tests for the identified employees no later than POC due date.
Type B
Section Cited
CCR
80072(a)(3)
80072 Personal Rights
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:
(3) To be free from... intimidation...coercion...or other actions of a punitive nature...
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above as one resident had monetary coercion implemented as a means to control unwanted behaviors which poses a potential personal rights risk to persons in care.
POC Due Date: 04/24/2025
Plan of Correction
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Licensee will submit their plan on how they will eliminate monetary coercion and how they will positively reinforce good habits for the resident no later than POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2025


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