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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603050
Report Date: 06/22/2022
Date Signed: 06/24/2022 12:38:09 PM

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
02/11/2022 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20220211084537
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:
06/22/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Pacita SerranoTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Resident sustained scabies while in care.
Staff did not seek medical attention to resident in care.
INVESTIGATION FINDINGS:
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On 06/22/2022, at 10:30 a.m., Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent unannounced visit to deliver the findings regarding the allegations above. The LPA was greeted by staff. The LPA spoke with the Licensee Pacita Serrano on the phone and explained the reason for the visit.

On 2/18/2022 at 2:00 p.m., Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct an initial 10-day visit. The LPA was greeted by staff Corazon Baldos, and staff called licensee Pacita Serrano. The LPA was informed that Pacita Serrano was on their way to the facility. Licensee arrived at the facility at 2:30 p.m., and the LPA explained the reason for the visit. LPA Urena interviewed staff, residents, and reviewed records from 2:30 p.m to 4:00 p.m.

Continues on LIC 9099 C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
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 6
Control Number 29-AS-20220211084537
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: 06/22/2022
NARRATIVE
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Regarding the allegation: Resident sustained scabies while in care.

It was alleged that R1 had contracted scabies while in care. To investigate this allegation, on 02/18/2022, at 2:30 p.m., the LPA interviewed residents, staff, and the Administrator, and conducted record review. The LPA reviewed five out of five files. The record review revealed that no other resident residing at the facility had exhibited eye conditions related to the allegation within the past two months. The residents interviewed stated that they had not experienced any eye conditions within the last two months. The staff interviewed revealed that no other resident nor staff at the facility exhibited the same eye condition as R1. The administrator stated that they were not aware of any other resident or staff with eye conditions, with the exception of R1, as it was brought to their attention on 02/10/2022 by the Day Program. R1 attends the Day Program five days a week, from 9:00 a.m. to 1:30 p.m. Per the interview with the Day Program staff on 2/17/2022, the staff noticed the eyelid swollen and red on 02/10/2022, however the staff did not see any irregularities or eyelid conditions on R1 the day before on 2/09/2022.

Based on the observations, and the information gathered through the interviews and record review for the above allegation, there is insufficient evidence to support the claim that the ‘Resident sustained scabies while in care’. Therefore, although the allegation may have happened, or may be valid, this allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Staff did not seek medical attention to resident in care.

It was alleged that the facility staff did not seek medical attention for R1 while in care. R1 arrived at the Day Program with a red, and swollen eyelid on 02/10/2022. On 02/17/2022, at 2:37 p.m., the LPA interviewed the Reporting Party (RP) about the condition of R1’s eyelid. Per the RP, on 02/10/2022, R1 arrived at the Day Program at 9:00 a.m., and at approximately 9:22 a.m., they observed that R1’s eyelid was swollen, and red. The LPA asked the RP if R1 had attended the Day Program on 02/09/2022, and if the eye condition was observed on this day? The RP stated, “Yes, the R1 was present at the Day Program on 02/09/2022, and ‘No’ there was nothing wrong with R1’s eyelid on 02/09/2022”. On 02/18/2022, the LPA interviewed R1 about the condition of the eyelid. The R1 stated that the eye was itchy on the first day the condition was apparent.

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

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20220211084537
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: 06/22/2022
NARRATIVE
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The LPA interviewed the staff (S1), and the facility administrator about the condition of R1’s eyelid before leaving the facility to the Day Program. The S1 stated that they did not notice anything wrong with R1’s eyelid; R1 wears glasses and consequently, they did not notice any changes. The administrator stated that R1 wears glasses and may be the reason why staff did not notice the redness of the eyelid. On 02/18/2022, the LPA reviewed physicians’ notes for R1’s eyelid condition. The report revealed that R1 was seen by the physician on 02/10/2022 at approximately 12:53 p.m. R1 was picked up by the responsible party from the Day Program on 02/10/2022, due to the facility’s administrator being indisposed and staff not having a vehicle to pick up R1 from the Day Program.

Based on the observations, and the information gathered through the interviews and record review for the above allegation, there is insufficient evidence to support the claim that staff did not seek medical attention for resident while in care. Therefore, although the allegation may have happened, or may be valid, this allegation is deemed Unsubstantiated at this time.

Exit interview conducted. Today's reports was reviewed with Administrator Pacita Serrano over the phone. Facility representative signed the report. Copy of the report was issued.

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

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
02/11/2022 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20220211084537

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:
06/22/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Pacita SerranoTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Facility did not have available transportation.
INVESTIGATION FINDINGS:
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On 06/22/2022, at 10:30 a.m., Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent unannounced visit to deliver the findings regarding the allegations above. The LPA was greeted by staff. The LPA spoke with the Licensee Pacita Serrano on the phone and explained the reason for the visit.

On 2/18/2022 at 2:00 p.m., Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct an initial 10-day visit. The LPA was greeted by staff Corazon Baldos, and staff called licensee Pacita Serrano. The LPA was informed that Pacita Serrano was on their way to the facility. Licensee arrived at the facility at 2:30 p.m., and the LPA explained the reason for the visit. LPA Urena interviewed staff, residents, and reviewed records from 2:30 p.m. to 4:00 p.m.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20220211084537
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: 06/22/2022
NARRATIVE
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Regarding the allegation: Facility did not have available transportation.

It was alleged that when the Day Program called the residential facility to pick up R1 from the day program due to a medical situation, the facility staff stated that they did not have a car on site to pick up R1. On 2/17/2022 at approximately 2:37 p.m., the LPA interviewed the Reporting Party (RP) about the allegation, and the RP stated that they attempted to contact the administrator about picking up R1 from the day program, but was told by the facility staff that the administrator was in a meeting. The LPA interviewed the administrator on 02/18/2022 about the transportation services for the residents, and the administrator stated that they were ‘indisposed’ on 02/10/2022, therefore they were not available to pick up R1 up from the day program. The administrator stated that on hindsight they could have used the Uber services to pick up R1 from the day program.

Based on the observations, and the information gathered through the interviews for the above allegation, there is evidence to support the claim that the ‘facility did not have available transportation’. Therefore, this allegation is deemed Substantiated at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D).


Citations were issued. Exit interview conducted. Today's reports, and appeal rights were reviewed with Administrator Pacita Serrano over the phone. Facility representative signed the report. Copy of the report was issued.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20220211084537
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: 06/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2022
Section Cited
CCR
87465(a)(2)
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87465(a)(2) - Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility… (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation...The facility did not meet the requirements as evidenced by:
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The Licensee agreed to read, review and have a complete understanding of regulation 87465(a)(2) and provide a signed statement of understating of requirements/regulation by 06/30/2022.
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Based on staff, and witness interviews, the licensee did not comply with the above regulation, the facility did not meet transportation needs for the resident, 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: 06/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6