197608975-4-15-2021-31-AS-CHAS-C4FTXY-20210629150754

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608975
Report Date: 04/15/2021
Date Signed: 04/15/2021 07:14:06 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/13/2020 and conducted by Evaluator Yelena Avetisyan

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20201113094212

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:	04/15/2021
		UNANNOUNCED	TIME BEGAN:	05:25 PM
MET WITH:	George Bat		TIME COMPLETED:	05:45 PM

ALLEGATION(S):

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Licensee failed to meet fire safety requirements
Facility has pests
Facility staff violated R1's personal rights

INVESTIGATION FINDINGS:

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An unannounced subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. Upon arrival LPA met with staff George Bat who contacted administrator Ella Mastov via phone. LPA spoke with the administrator and informed her the reason for the visit. LPA provided the findings of the investigation. Ms. Mastov was unable to come to the facility and designated staff to sign for the report.

In regard to the allegation of Licensee failed to meet fire safety requirements it is being alleged that the facility gates are locked and residents are not able to leave the facility, On 11/20/2020 and on 11/23/2020 LPA visited and inspected the outside of the property including but not limited to fence/gate located on the property. During both visits the gates were unlocked and easily opened and closed. On 11/23/2020 LPA conducted interviews with administrator and 2 caregivers. All staff denied locking the facility gate or doors in a manner that would prevent residents from leaving the facility. Based on the information obtained allegation is Unsubstantiated at this time.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena Avetisyan	TELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021

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

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20201113094212

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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
	VISIT DATE: 04/15/2021

NARRATIVE

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It was also reported that the facility has pests. On 11/17/2020 LPA conducted interview with responsible party for resident 1 (R1) who was named in the complaint. On 11/23/2020 LPA conducted a virtual tour of the facility and interviewed staff. Interviews conducted revealed that R1 has a eye condition which causes him to see spots. R1 believes that the spots are bugs. All parties interviewed denies that the facility has pests/bugs. Additionally during the virtual tour LPA did not observe pest/bugs. Based on the information obtained during the course of the investigation the allegation is Unsubstantiated at this time.

In regards to allegation of Facility staff violated R1's personal rights it was reported that facility staff took R1's laptop and made changes resulting in R1 not being able to go online. During the course of the investigation LPA conducted interview of administrator, staff and R1's responsible party. Staff interviewed denied taking R1's laptop and/or making any changes it. R1's responsible party stated that the laptop R1 uses is very old and does not work well. Based on the information obtained the allegation is Unsubstantiated at this time.

Exit interview was conducted/ Copy was provided via email.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena Avetisyan	TELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021

LIC9099 (FAS) - (06/04)

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