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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609368
Report Date: 01/28/2025
Date Signed: 03/11/2025 10:44:34 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
01/24/2025 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20250124110820
FACILITY NAME:SERENITY VILLA ASSISTED LIVINGFACILITY NUMBER:
197609368
ADMINISTRATOR:MARTINEZ, JERRILYNFACILITY TYPE:
740
ADDRESS:43126 FENNER AVETELEPHONE:
(661) 557-3434
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 1DATE:
01/28/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Francisco Martinez (Administrator)TIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff do not provide adequate food service
INVESTIGATION FINDINGS:
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On 01/28/25, Licensing Program Analyst (LPA) Evelin Rios conducted an initial unannounced complaint visit to address a specific allegation. After further review it was determined that the allegation addressed on 01/28/25 visit was not applicable to California Code of Regulations, Title 22, Division 6, Chapter 8. On 03/11/25 LPA Rios amended the initial report to address the appropriate allegation mentioned above and deliver a determination. LPA arrived at the facility at 10:15 a.m. and was greeted by the administrator Francisco Martinez. LPA explained the purpose of the visit. An entrance interview was conducted.

On 01/28/2025 at 10:24 a.m., LPA conducted a physical plant tour to ensure the health and safety of the residents in care. During this tour, at approximately 10:27 a.m., LPA interviewed resident #1 (R1). At approximately 10:30 a.m., LPA conducted an interview with the administrator. At 11:00 a.m., LPA reviewed the facility's Licensing Information System (LIC) facility profile, Guardian Background Check System, employee roster, and facility sketch. (Cont. to LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
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 3
Control Number 31-AS-20250124110820
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SERENITY VILLA ASSISTED LIVING
FACILITY NUMBER: 197609368
VISIT DATE: 01/28/2025
NARRATIVE
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(Continued from LIC9099) Allegation: Staff do not provide adequate food service. The allegation was reported as "facility food was not good." To investigate the allegation, LPA Rios interviewed resident #1 (R1) and the administrator. The administrator explained that meals are prepared by him or one other staff, and emphasized that they do not prepare meals they wouldn't eat themselves. Additionally, the administrator has not received complaints about the food provided. LPA's interview with R1 revealed that they eat the meals provided, have not refused food, and have not requested substitutes. R1 also mentioned that they like to have the same meal for breakfast and communicate this request to the administrator without issues. LPA observed a sufficient supply of two days perishable food and seven days non-perishable food, all properly stored. Based on interviews and LPA's observations, the allegation is deemed Unsubstantiated at this time.

Exit Interview Conducted. Copy of report provided.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20250124110820
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SERENITY VILLA ASSISTED LIVING
FACILITY NUMBER: 197609368
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3