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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197608975
Report Date:
06/30/2021
Date Signed:
06/30/2021 01:31:34 PM
COMPREHENSIVE INSPECTION
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 CARE
FACILITY NUMBER:
197608975
ADMINISTRATOR:
MASTOV, ELLA
FACILITY TYPE:
740
ADDRESS:
6658 CAPISTRANO AVE
TELEPHONE:
(747) 242-1916
CITY:
WEST HILLS
STATE:
CA
ZIP CODE:
91307
CAPACITY:
6
CENSUS:
6
DATE:
06/30/2021
TYPE OF VISIT:
Case Management - Annual Continuation
UNANNOUNCED
TIME BEGAN:
11:35 AM
MET WITH:
Luz Angela Martinez, Lily Pyarali
TIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angelica Arambulo conducted an unannounced required annual visit to the facility. LPA met with staff Luz Martinez and administrator LIly Pyarali. The mitigation plan has been submitted but no final approval was received yet.
The LPA reviwed the facility file and observed that a mitigation plan was submitted.
A tour of the facility was conducted and staff did screen and document LPA at entry. The LPA checked each resident rooms for compliance. All residents were in the living room watching tv. The signage for Covid 19 and hand washing was posted through out the facility.
Visit completed. report issued with no deficiencies.
SUPERVISOR'S NAME:
Eva Miller
TELEPHONE:
(818) 596-4373
LICENSING EVALUATOR NAME:
Angelica Arambulo
TELEPHONE:
(818) 389-7921
LICENSING EVALUATOR SIGNATURE:
DATE:
06/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/30/2021
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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