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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608975
Report Date: 06/25/2021
Date Signed: 06/30/2021 01:10:01 PM

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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:MY SERENITY BOARD AND CAREFACILITY NUMBER:
197608975
ADMINISTRATOR:MASTOV, ELLAFACILITY TYPE:
740
ADDRESS:6658 CAPISTRANO AVETELEPHONE:
(747) 242-1916
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:6CENSUS: 6DATE:
06/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ariel Mastov/ AdministratorTIME COMPLETED:
11:00 AM
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THIS REPORT WAS CREATED IN ERROR. THIS WAS INTENDED FOR MY SERENITY SENIOR HOME.


Licensing Program Analyst (LPA) Patrick Shanahan, Angela Panushkina, and Melissa Ruiz conducted an Annual Required visit and inspection of the facility. LPA met with Ariel Mastov. LPA explained the reason for the visit.

A tour of the physical plant was conducted. All smoke alarms were tested and function properly. The fire extinguisher was last serviced on 3/21/21 . The carbon monoxide detector was tested and functions properly.
Kitchen: The kitchen appeared clean and the appliances and fixtures functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives and detergents were stored in locked drawers and cabinets. Properly labeled medications were locked in a cabinet near the kitchen. Bedrooms: There were four bedrooms designated for residents' use and one staff bedroom. All bedrooms were clean, properly furnished and had sufficient lighting. Bathrooms: There were two bathrooms designated for residents' use. Both bathrooms were clean, properly supplied and had functional fixtures. Hot water temperature was 116.3 degrees Fahrenheit. Cleaning supplies were kept in locked cabinets. Common Areas: These included the living room and dining area. The common areas appeared clean and were properly furnished. Surrounding Grounds: Entry/exits were free of obstruction. The outdoor area was clean and free of hazards.


Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the no deficiencies were cited : Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
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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