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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603050
Report Date: 04/23/2024
Date Signed: 04/23/2024 02:34:44 PM

Document Has Been Signed on 04/23/2024 02:34 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:VILLA SERRANO CARE HOMEFACILITY NUMBER:
197603050
ADMINISTRATOR/
DIRECTOR:		PACITA R. SERRANOFACILITY TYPE:
735
ADDRESS:11937 COHASSET STREETTELEPHONE:
(818) 503-7124
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 4DATE:
04/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:42 PM
MET WITH:Teresita Jacinto, staff TIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 12:45 p.m., the LPA met with staff and explained the reason for the visit. The Licensee was not available to meet the LPA and authorized staff, Teresita Jacinto to sign the report.

Starting at 12:50 p.m., the LPA, along with staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards.

KITCHEN: The LPA observed the kitchen and dining area. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 1:01 p.m., hot water measured at 106.2-degree Fahrenheit. Knives are stored in a locked pantry. BEDROOMS: The facility is a single-story residential home with seven (7) bedrooms, four (4) for client use and three (3) for staff use. The LPA observed client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. RESTROOMS: The facility has three (3) restrooms. Client restroom is relatively clean and sanitary and in operating condition with grab bars and non-skid materials. At 1:05 p.m., hot water measured at 105.6-degree Fahrenheit. The sink had sufficient liquid soap, and paper towels. OUTDOOR SPACE: At 1:07 p.m., the LPA observed the back patio which has a covered outdoor area for client use. There are no bodies of water on the premises. The LPA observed three (3) locked storage sheds in the back patio. COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished. The LPA observed the fire extinguisher to be fully charged and last serviced on 02/28/2024. The laundry units are located near the living room area. Medications, first aid kit and additional supplies are located in a locked storage closet near the living area.

Continued on LIC 809-C.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2024
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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Document Has Been Signed on 04/23/2024 02:34 PM - It Cannot Be Edited


Created By: Emily Peraldi On 04/23/2024 at 02:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLA SERRANO CARE HOME
FACILITY NUMBER: 197603050

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as three (3) smoke detectors were inoperable/ need replacement of batteries which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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Staff stated that they will fix the smoke alarms that are inoperable or in need of batteries and send proof to the LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Emily Peraldi
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024


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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLA SERRANO CARE HOME
FACILITY NUMBER: 197603050
VISIT DATE: 04/23/2024
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Carbon monoxide detector was tested during the time of the visit and functioned properly. Three (3) smoke detectors, throughout the facility were inoperable and need replacement of batteries.

At 2:11 p.m., the LPA interviewed one (1) client, no concerns noted.

Pursuant to Title 22 of the California Code of Regulations Division 6, the following deficiency was cited (refer
to LIC 809-D).

Due to time constraints the LPA will return to complete the annual at a later date.

Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024
LIC809 (FAS) - (06/04)
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