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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603050
Report Date: 08/01/2022
Date Signed: 08/01/2022 06:47:21 PM

Document Has Been Signed on 08/01/2022 06:47 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
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: 6DATE:
08/01/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Pacita SerranoTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Ashley Smith and Sandra Urena conducted an unannounced Case Management – Other visit, for the purposes of conducting a comprehensive annual. The LPAs met with staff and explained the reason for the visit. Administrator Pacita Serrano arrived at approximately 2:00 p.m.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Kitchen: The kitchen area was observed at 10:05 a.m. The facility has a sufficient supply of non-perishable and perishable food items. During today’s visit, the LPAs found expired food. The LPAs discovered the following: bread expired 7/27/2022, two packages of hot dog buns expired 7/24/2022, two boxes of muffin mix expired 6/2021, salad dressing that expired 2021. In addition, salad dressing was stored open in the cabinet, and the LPAs asked staff to discard these items. The LPAs found lighters and matches accessible in a drawer at 10:25 a.m. At 10:27 a.m., the LPAs found unsecured medication in the refrigerator. Staff stated it was their medication. Cleaning supplies and disinfectants are stored inaccessible. Knives are stored in a locked cabinet in the kitchen. At 10:20 a.m., the hot water temperature in the kitchen measured at 108.7 degrees Fahrenheit.

Restrooms: Fixtures in the client restrooms were in operating condition. The shower in the shared client bathroom in the hallway was unkempt. The non-skid mat observed in the shower appeared to be unclean. At 10:37 a.m., the hot water in the common hallway bathroom measured at 108.5 degrees Fahrenheit.

Bedrooms: The LPAs toured the client rooms. Furniture was observed in disrepair in Room #2, Room #3, Room #4 and Room #6. A linen closet was located outside of the rooms, which stocked extra linens and towels.

CONT 9099-C

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLA SERRANO CARE HOME
FACILITY NUMBER: 197603050
VISIT DATE: 08/01/2022
NARRATIVE
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Common areas: Living and dining room furniture were in good condition. The blinds in the kitchen and living room were in disrepair. The washer and dryer are on site; however, cleaning supplies were accessible above the washer and dryer. The fire extinguisher was charged and serviced 4/2022. The backyard has a covered patio with furniture for the clients to use. The LPAs observed an outdoor freezer with food inside. However, the freezer was emitting an odor and food was not properly covered. There were bottles, trash, and bags with unidentified items that needed to be removed from the backyard. There were no bodies of water noted.

Records: The LPA reviewed client and staff records at 11:00 a.m. The LPAs reviewed files for, but not limited to, the following: admission agreements, medical assessments with TB results, consent forms, and current needs and services plan. Out of six files reviewed, all files were missing the personal rights form specific for community care licensing. Technical violation issued. Four out of six files need an updated appraisal (Client #1, Client #2, Client #3, Client #5). Four staff files were reviewed. The LPAs reviewed files for, but not limited to: personnel records, health screening, criminal record statements, current first aid/CPR cards. The training records from January 2022 - present were incomplete, as there were no staff signatures on all training documents at the time of observation. Otherwise, files were complete. The facility is vendored by North Los Angeles Regional Center (NLARC) as a level 3 home. The administrator's certificate expires on 6/12/2023. The disaster drill was last conducted on 10/14/2021.

Medications: Medications were reviewed at 11:45 a.m. Medications are centrally stored in a locked cabinet in the dining room. The LPAs could not identify current centrally stored medication and destruction records for two out of six clients (C3, C4). The medications for Client #1 (C1) were delivered late and C1 did not receive their morning dosages until the afternoon. The Administrator claimed it was an error on the pharmacy and alleged they called the pharmacy daily since 7/29/2022 regarding C1's medications. C1 has been at the facility since 6/24/2022.

Other: The LPAs spoke to the Administrator about an incident with Client #3. On 7/23/2022, it was reported that while C3 was having a behavioral episode, Staff #1 (S1) allegedly became startled, threw water in the direction of C3 , and the water hit C3 on their side. An in-service training was held regarding client personal rights. At the time of this visit, the administrator communicated that S1 resigned.

The following deficiencies were observed (See LIC 809-D.) and cited from the CACode of Regulations, Title 22. Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2022
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 08/01/2022 06:47 PM - It Cannot Be Edited


Created By: Ashley Smith On 08/01/2022 at 03:41 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: 08/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/01/2022
Section Cited
CCR
80075(k)(1)

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80075(k)(1) Health Related Services. Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
1. Secure the medications. This happened during today's visit. Plan of Correction met.
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Based on observation, the licensee did not comply with the section cited above, as medications were accessible in the refrigerator and the dining area, which poses an immediate health and safety risk to clients in care.
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Type A
08/01/2022
Section Cited
CCR80087(g)

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80087(g) Building and Grounds. (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
1. Secure the items. This happened during today’s visit. Plan of Correction met.
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Based on observation, the licensee did not comply with the section cited above as lighters and matches were accessible in a kitchen drawer, and cleaning supplies in the laundry area, which poses an immediate health and safety risk to clients 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.
SUPERVISOR'S NAME:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Ashley Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/01/2022 06:47 PM - It Cannot Be Edited


Created By: Ashley Smith On 08/01/2022 at 03:42 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: 08/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/02/2022
Section Cited
CCR
80075(b)

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80075(b) Health Related Services. (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
1. Submit a Plan of Action, indicating how the licensee plans to ensure that all clients obtain their medications timely. Submit plan by 8/2/2022
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Based on observation, the licensee did not comply with the section cited above, as one out of six clients (C1) did not have their morning medications until noon, which poses an immediate health and safety risk to clients in care.
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Type B
08/05/2022
Section Cited
CCR80076(a)(1)

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80076(a)(1) Food Service. All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
1. Audit food; throw out food that is in poor quality. Inform CCL when this has happened, but no later than 8/5/2022
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Based on observation, the licensee did not comply with the section cited above, as there was expired food in the refrigerator and observed in the backyard freezer, 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.
SUPERVISOR'S NAME:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Ashley Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/01/2022 06:47 PM - It Cannot Be Edited


Created By: Ashley Smith On 08/01/2022 at 03:44 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: 08/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/05/2022
Section Cited
CCR
80087(a)

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80087(a) Building and Grounds. The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
1. Submit a plan to the Department, detailing how the furniture will be replaced and the timeline of completion. Plan must be submitted by 8/5/2022, and furniture must be repaired or replaced by 8/22/2022.
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Based on observation, the licensee did not comply with the section cited above, as there was furniture observed in client rooms in disrepair, hallway bathroom was unclean, and blinds were in disrepair, which poses a potential health and safety risk to clients in care.
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2. Replace the non-skid mat in the hallway restroom. Clean the client shower. Inform CCL when this has happened, but no later than 8/5/2022.
Type B
08/05/2022
Section Cited
CCR80087(c)

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80087(c) Building and Grounds. 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:
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The Administrator agreed to do the following:
1. Submit a plan to the Department, detailing how the identified items in the backyard will be removed. Plan must be submitted by 8/5/2022, and items must be removed 8/22/2022. Submit photos or statement of completion by 8/22/2022.
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Based on observation, the licensee did not comply with the section cited above, as passageways in the backyard are cluttered, which poses a potential health and safety risk to clients 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.
SUPERVISOR'S NAME:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Ashley Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2022


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 08/01/2022 06:47 PM - It Cannot Be Edited


Created By: Ashley Smith On 08/01/2022 at 03:47 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: 08/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/22/2022
Section Cited
CCR
80068.3(a)

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80068.3(a) Modifications to Needs and Services Plan (a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually. This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
1. Update the appraisals for the clients by 8/22/2022.
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Based on the file review, the licensee did not comply with the section cited above in four out of six client files (Client #1, Client #2, Client #3, Client #5), which poses a potential health and safety risk to residents in care.
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Type B
08/01/2022
Section Cited
CCR80072(a)

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80072(a) Personal Rights. (a) Each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement is not met as evidenced by:
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The Administrator has already conducted training with the staff in question on 7/27/2022. In addition, the staff no longer works at this facility. Plan of Correction met.
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Based on interview, the licensee did not comply with the section cited above, as S1 threw water in C3’s face, which poses an immediate personal rights violation to clients 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.
SUPERVISOR'S NAME:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Ashley Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2022


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 08/01/2022 06:47 PM - It Cannot Be Edited


Created By: Ashley Smith On 08/01/2022 at 04:34 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: 08/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2022
Section Cited
CCR
80023(d)

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80023(d) Disaster Drills. Disaster drills shall be conducted at least every six months.
This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
1. Conduct a disaster drill; submit sign-in sheet by 8/12/2022.
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Based on record review, the licensee did not comply with the section cited above, as the last disaster drill was conducted 10/2021, which poses a potential health and safety risk to clients 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.
SUPERVISOR'S NAME:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Ashley Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2022


LIC809 (FAS) - (06/04)
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