197603050-8-12-2022-29-AS-JAPL-CJ9TG8-20220914144236

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603050
Report Date: 08/11/2022
Date Signed: 08/12/2022 10:40:30 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
08/02/2022 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20220802113334

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: 6	DATE:	08/11/2022
		UNANNOUNCED	TIME BEGAN:	01:14 PM
MET WITH:	Pacita Serrano		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff poured water on resident in care.
Staff do not treat resident with dignity and respect.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced visit to investigate the above allegations. The LPA arrived at 1:15 pm, spoke with the administrator, and explained the reason for the visit.

At 1:20 p.m., LPA and the staff conducted a brief tour of the facility at 1:25 p.m.. No deficiencies were found. At 1:30 p.m., the LPA conducted record review. During today's visit the LPA noticed three individuals in the facility, in addition to the caregivers. One individual was fixing the printer, and two individuals were visiting. Individuals left while LPA was conducting file review.

Staff poured water on resident in care.
On the allegation, ‘Staff poured water on resident in care’. This allegation has been addressed during the Case Management visit conducted on 08/01/2022. The allegation was substantiated. No additional citations will be issued at this time. Continues on LIC 9099 C...

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220802113334

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: 08/11/2022

NARRATIVE

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Staff do not treat resident with dignity and respect.

On the allegation, ‘Staff do not treat resident with dignity and respect’. This allegation has been addressed during the Case Management visit conducted on 08/01/2022. The allegation was substantiated. No additional citations will be issued at this time.

No citations were issued. Exit interview was conducted with licensee. A copy of the report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

LIC9099 (FAS) - (06/04)

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