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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608975
Report Date: 08/28/2026
Date Signed: 08/28/2026 05:01:52 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/28/2026 05:01 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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:MY SERENITY BOARD AND CAREFACILITY NUMBER:
197608975
ADMINISTRATOR/
DIRECTOR:		MASTOV, ELLAFACILITY TYPE:
740
ADDRESS:6658 CAPISTRANO AVETELEPHONE:
(747) 242-1916
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY: 6CENSUS: 6DATE:
08/28/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Ella MastovTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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At 11:00 a.m. on 08/28/26, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and later the licensee and disclosed the reason for the visit. LPA and the staff toured the facility inside and out.

The facility was last visited on 03/10/26 for a complaint visit. It is a single story building with five (05) bedrooms, four (04) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for six (06) residents, of which five (05) may be nonambulatory and one (01) bedridden. The facility serves residents with dementia. Approved hospice waivers for six (06).

At the main entrance, LPA observed postings for the facility’s visitation policy, staff and resident rosters, emergency disaster plan, facility sketch and license, personal rights, and blank copy of the admission agreement. Additional postings were observed inside for confidential complaint contacts, emergency contacts, rights of resident councils, and ombudsman contacts. A screening station at the front contained a visitor log. Walls, floors, windows, screens, and blinds were clean and in good repair. At 11:15 a.m. LPA measured the room temperature to be 75 degrees Fahrenheit.

At 11:20 a.m., five (05) out of six (06) residents were observed conversing and watching television in the living room together. The living room contained a piano, musical equipment, reading material, art supplies, and exercise equipment. Two (02) hallway closets had board games, puzzles, and art supplies, PPE, and an adequate supply of fresh linens. Emergency lights were hung throughout the hallways.

The facility has five (05) bedrooms. The bedroom nearest the main entrance is designated as a staff room. The staff room was locked. Of the four (04) resident bedrooms, two (02) are shared and two (02) are private.

Naira Margaryan
Nicholas Reed
DATE: 08/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MY SERENITY BOARD AND CARE
FACILITY NUMBER: 197608975
VISIT DATE: 08/28/2026
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Bedroom #3 has a sign stating “No smoking – Oxygen in use”. Bedroom #3 and Bedroom #4 have private bathrooms. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. All hospital-style beds with wheels were in the locked position.

The facility has four (04) bathrooms. All bathrooms contained liquid soap, paper towels, trash cans with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. Commodes and shower chairs were also available. At approximately 11:35 a.m. LPA measured the water temperature in the shared bathroom to be 111.9 degrees Fahrenheit.

LPA observed an adequate supply of perishable and non-perishable foods in the kitchen. Appliances were in good condition. Cleaning solutions were locked below the sink and in a separate cabinet near the staff room. Sharps were locked in a lock box in a drawer below the counter top. Medications were locked in a cabinet near the refrigerator.

A washing machine and dryer were located outside of the kitchen. Both were in working order. Detergents were locked in a storage container next to the appliances. LPA observed two (02) covered, shaded patio areas in the rear and side of the facility. The patio contained furniture in good condition. Ramps were secure and had sturdy hand rails. Ramps led out from the living room and Bedroom #3. Two (02) out of two (02) emergency exit paths were free from tripping hazards. There was a locked storage shed with extra supplies. The pool was fenced, locked, and inaccessible. The exit gate was unlocked with a self-closing, inward facing latch. Evacuation routes were posted. Four (04) out of four (04) auditory alarms were turned on and functioning.

At approximately 11:45 a.m., smoke and carbon monoxide detectors were tested and operational. When tested, the fire door in front of the main hallway closed automatically. At approximately 12:00 p.m. the house telephone was called and deemed to be operational. At 12:10 p.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last inspected on 06/30/26 and had a tag attached.

At 12:30 p.m. LPA reviewed resident and personnel files. Files were complete and available for audit.

During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed.

Exit interview conducted. Copy of report provided.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2026
LIC809 (FAS) - (06/04)
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