197603050-4-1-2022-29-AS-SURA-CD3UVT-20220401155540

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603050
Report Date: 04/01/2022
Date Signed: 04/01/2022 03:56:20 PM

Document Has Been Signed on 04/01/2022 03:56 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 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: 5	DATE:	04/01/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Eleanor De la Cruz		TIME COMPLETED:	12:00 PM

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On 04/01/2022, Licensing Program Analyst (LPA) Sandra Urena, arrived at the facility at 9:30 a.m., unannounced to conduct a required annual inspection. This annual inspection had a specific emphasis on infection control practices and procedures. LPA Urena met with staff Eleanor De La Cruz, and explained the reason for the visit. Staff called administrator Pacita Serrano on the phone, and the LPA explained the reason for the visit.

Infection Control: Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

At 10:00 a.m., LPA Urena and staff conducted a tour of the inside and outside the facility to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Common Areas: At 10:15 a.m., LPA Urena observed the walls and flooring to be in good condition. At the time of the visit, common seating area, and dining room furniture was observed to be clean and in good condition.

Kitchen: At 10:30 a.m., LPA Urena observed the kitchen/dining area. Knives are stored in a locked cabinet drawer. Kitchen appliances were in operable condition. The facility has enough supply of perishable and non-perishable food. Freezer and refrigerator are stocked with a variety of foods. Emergency food supply is adequate for six residents and two staff.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022

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

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLA SERRANO CARE HOME	FACILITY NUMBER: 197603050
	VISIT DATE: 04/01/2022

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Bedrooms: At 10:50 a.m., LPA Urena checked beds for bed bug infestation.During today's visit the LPA looked closely for signs of infestation and did not find bugs this time. The mattresses in each one of the bedrooms were covered with a plastic mattress cover. Bedrooms were furnished appropriately with appropriate furnishings and sufficient lighting. Linens are clean, and in good condition.

Bathrooms: At 11:15 a.m., LPA Urena observed the residents’ restroom. Restroom was clean, shower area was in clean condition with grab bars, and a non-skid mat available. Paper towels were available for drying hands. Hand washing signs were displayed, and sufficient amounts of soap and paper products in each restroom.

Outdoor Space: At 11:30 a.m., LPA Urena observed the Outdoor space. Backyard has a covered outdoor area equipped with outdoor furniture for residents’ use. There were no bodies of water noted. Side gate is unlocked.

No deficiencies cited during this visit. Exit interview was conducted. The report was reviewed with staff, signatures were obtained, and a copy of the report was provided.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022

LIC809 (FAS) - (06/04)

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