197608975-8-28-2026-31-AS-NMAN-DZARWK-20261028132313

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608975
Report Date: 08/28/2026
Date Signed: 08/28/2026 05:05:03 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/09/2026 and conducted by Evaluator Nicholas Reed

COMPLAINT CONTROL NUMBER: 31-AS-20260309174013

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:	08/28/2026
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Ella Mastov		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Resident developed multiple pressure injuries due to staff neglect

INVESTIGATION FINDINGS:

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At approximately 11:00 a.m. on 08/28/26, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and disclosed the reason for the visit.

To investigate the allegations above, LPA conducted an initial visit on 03/10/26 and toured the facility at 9:15 a.m. and conducted a record review of pertinent records, including but not limited to an admission agreement, medical assessment, care plan, and staff and client rosters at 9:25 a.m. LPA obtained and reviewed hospital records at 11:30 a.m. on 06/03/26 and home health records at 12:30 p.m. on 07/01/26. LPA also interviewed Witness #1 (W1) at 1:30 p.m. on 06/10/26 and R1’s home health nurse at 4:15 p.m. on 07/01/26. Today, LPA interviewed staff and residents between 11:15 a.m. and 3:30 p.m. and toured the facility inside and out at 11:20 a.m.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR 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

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/09/2026 and conducted by Evaluator Nicholas Reed

COMPLAINT CONTROL NUMBER: 31-AS-20260309174013

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:	08/28/2026
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Ella Mastov		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Staff did not meet resident's toileting needs
Staff hit resident
Staff mismanaged resident medication

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR 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

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 31-AS-20260309174013

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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

NARRATIVE

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Regarding the allegation "Staff did not meet resident's toileting needs" it was alleged staff did not change R1’s diaper as needed. Interview with W1 revealed R1 was wet and needed changing during several visits. Interviews with five (05) out of six (06) residents revealed no pertinent information. Interview with Resident #2 (R2) at 11:40 a.m. today revealed staff meet their toileting needs. Interview with S1 revealed they emptied R1’s catheter and changed their diaper. Home health was responsible for cleaning R1’s catheter. Interview with the administrator revealed R1 had irregular bowel movements due to multiple medications. Staff changed R1 as needed. Record review of R1’s medical assessment revealed they were incontinent for their bladder and used a Foley catheter. R1’s care plan revealed the facility agreed to monitor the catheter for output and infection. Staff care logs tracked bowel and bladder movements of R1. Based on interviews and record review, it was concluded that although the allegation may have occurred, there is not enough measurable and verifiable information to confirm validity of the complaint. Hence the allegation is UNSUBSTANTIATED at this time.

Regarding the allegation "Staff hit resident" it was alleged a caregiver hit R1 on the head. Interview with W1 revealed they were told Staff #1 (S1) hit R1 on the head in February 2026. Interviews with five (05) out of six (06) residents revealed no pertinent information. Interview with R2 revealed staff treat their well and do not abuse residents. Staff interviews also revealed no instances of staff abusing residents. Interview with the administrator confirmed no staff have abused residents. Based on interviews and record review, it was concluded that although the allegation may have occurred, there is no measurable and verifiable information to confirm validity of the complaint. Hence the allegation is UNSUBSTANTIATED at this time.

Regarding the allegation "Staff mismanaged resident medication" it was alleged staff assisted R1 with a discontinued medication. Interview with W1 indicated the medication was Cyclobenzaprine HCL 5mg. Interviews with five (05) out of six (06) residents revealed no pertinent information. Interview with R2 revealed staff assist them with medications appropriately. Interviews with S1, S2, and the administrator revealed all staff follow physician orders. S1 and S2 could not recall the frequency they provided R1 with Cyclobenzaprine. The administrator stated R1’s family brought in medications without orders. Record review of R1’s face sheet revealed R1 was prescribed the medication at their skilled nursing facility on 01/30/26. It was to be given three (03) times daily, every eight (08) hours. A photograph of R1’s medication container showed their Cyclobenzaprine was refilled on 02/09/26 with orders to “Take 1 tablet by mouth in the morning, noon, and at bedtime” which was consistent with the original physician orders.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR 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

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 31-AS-20260309174013

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Based on observations, interviews, and record review, it was concluded that although the allegation may have occurred, there is no measurable and verifiable information to confirm validity of the complaint. Hence the allegation is UNSUBSTANTIATED at this time. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR 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

LIC9099 (FAS) - (06/04)

Page: 6 of 6

Control Number 31-AS-20260309174013

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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

NARRATIVE

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Regarding the allegation "Resident developed a pressure injury due to staff neglect" it was alleged Resident #1 (R1) developed an unstageable pressure injury due to lack of appropriate care from staff. R1 was unavailable for interviews. Interview with the administrator at 1:30 p.m. today revealed R1 was admitted to the home with a Stage 2 pressure injury on their right heel and coccyx on 02/05/26. R1 also had home health with wound care orders. Interview with Staff #1 (S1) at 11:15 a.m. today revealed R1’s home health nurse educated staff on wound care instructions. S1 repositioned R1 as instructed every two (02) hours, changed dressings when needed, and ensured the area was dry. R1’s wound was “healing at first”. Interview with Staff #2 (S2) at 11:25 a.m. today revealed only S1 cared for R1’s pressure injury. Interview with R1’s home health nurse confirmed R1 began receiving home health wound care for Stage 1 pressure injuries on their coccyx and right heel on 02/05/26. Facility staff were educated on repositioning techniques and pressure-relieving methods to prevent further deterioration. By 02/10/26, the coccyx wound had progressed beyond Stage 2 to an Unstageable pressure injury. A nurse practitioner was consulted for additional measures to prevent wound deterioration, however additional measures like providing a low-air-loss mattress were not implemented until 03/03/26. By 03/09/26, R1 was hospitalized due to failure to thrive and an altered mental status. Record review of R1’s face sheet revealed they previously had an unstageable pressure injury on their right heel in 2025 and a fractured sacrum. R1 was admitted to this facility with orders from their skilled nursing facility for wound care of the heel. R1’s care plan also included instructions for “Pressure ulcer management, repositioning, heel protection, wound care”. Record review of home health records confirmed R1’s coccyx pressure injury had deteriorated to an unstageable pressure injury around 02/16/26. Records from 02/11/26 indicated a “continued redness… from non-repositioning including increased redness… and… size” Records from 02/16/26 and 02/23/26 revealed R1’s pressure injury had developed eschar, confirming the pressure injury was Unstageable. Home health records also noted continual education provided to facility staff to prevent further deterioration. Review of hospital records confirmed R1 had an unstageable pressure injury upon admission. Based on interviews and record review, the facility was aware of R1’s need for pressure injury management. Despite facility staff and home health measures to prevent wound progression, R1 developed an unstageable wound. Therefore, the allegation is deemed SUBSTANTIATED at this time. Deficiency issued on the corresponding LIC 9099-D page. Additionally, a $500 immediate civil penalty is assessed today for a violation resulting in injury to R1. The administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).
No immediate health or safety concerns observed during today's visit.
Exit interview conducted. Appeal Rights discussed. Copy of report provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR 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

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 31-AS-20260309174013

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/28/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 08/29/2026 Section Cited CCR 87615(a)(1)	1 2 3 4 5 6 7	87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained... (1) Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee discussed and agreed to conduct an in-service training by the POC due date.
	8 9 10 11 12 13 14	Based on interviews and revord review, the licensee did not comply with the section cited above in Resident #1 (R1) developing an instageable pressure injury while in care, which posed an immediate risk to the Health, Safety, or Personal Rights of persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2026

LIC9099 (FAS) - (06/04)

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