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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603050
Report Date: 08/22/2022
Date Signed: 08/26/2022 11:14:27 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 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:
08/22/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Corazon BaldosTIME COMPLETED:
01:13 PM
ALLEGATION(S):
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Staff did not follow resident's IPP and behavioral plan.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced subsequent visit to deliver the findings for the above allegations. The LPA arrived at 12:00 p.m. spoke with the administrator on the phone, and explained the reason for the visit.

On 8/11/2022, 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., the LPA and the staff conducted a brief tour of the facility at 1:25 p.m. At 1:30 p.m., the LPA conducted record review.

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

DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022
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 3
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: 08/22/2022
NARRATIVE
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On the allegation, ‘Staff did not follow resident's IPP and behavioral plan’, the LPA conducted additional record review on 08/22/2022. The information obtained revealed that the staff had received training on how to address Resident’s #1(R1) behavior, and were knowledgeable of R1’s Individual Personal Plan (IPP), and Behavioral plan. The facility’s staff action of pouring water on the R1 to address R1’s behavior was not included in the behavior plan. Therefore, the allegation that 'Staff did not follow resident's IPP, and behavioral plan', is deemed Substantiated at this time.

Per the California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited.

Exit interview was conducted, signatures obtained. A copy of the report and Appeal Rights were issued.

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

DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/22/2022
Section Cited
CCR
80072(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 did not follow R1’s IPP and behavioral plan to address R1 behavior,and threw water on resident, 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.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3