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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603050
Report Date: 02/24/2023
Date Signed: 02/27/2023 08:04:33 AM

Document Has Been Signed on 02/27/2023 08:04 AM - 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: 5DATE:
02/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Teresita JacintoTIME COMPLETED:
12:55 PM
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On 02/24/2022, Licensing Program Analyst (LPA) Sandra Urena, arrived at the facility at 11:55 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, and explained the reason for the visit. Staff called the Licensee Pacita Serrano on the phone, and the LPA explained the reason for the visit. Licensee explained that they would be unable to get to the facility for the inspection and staff was allowed to sign off the inspection report.

Infection Control: Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station.

LPA Urena and staff conducted a tour from 12:10 p.m. to 12:30 p.m. of the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Common Areas: The common area walls and flooring were observed 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: Knives are stored in a locked in the pantry. 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.

Continues on LIC 809C…

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2023
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: 02/24/2023
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Bedrooms: During today's visit the LPA looked closely for signs of bug infestation, and did not find bugs at 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: Bathroom was clean, shower area was in clean condition, 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: 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.



INFECTION CONTROL: During today’s visit, the LPA spoke with the staff regarding the facility’s
infection control practices. Upon entry, the facility has a point for symptom screening. The LPA observed an
adequate supply of Personal Protective 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. The facility’s policies and procedures as
it pertains to infection control is adequate.

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: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC809 (FAS) - (06/04)
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