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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600316
Report Date: 03/11/2025
Date Signed: 03/12/2025 02:28:26 PM

Document Has Been Signed on 03/12/2025 02:28 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SERRANO HOME CARE SERVICES, INC.FACILITY NUMBER:
198600316
ADMINISTRATOR/
DIRECTOR:		BIENAFE PAYUYOFACILITY TYPE:
735
ADDRESS:356 SOUTH SERRANO AVENUETELEPHONE:
(213) 385-0237
CITY:LOS ANGELESSTATE: CAZIP CODE:
90020
CAPACITY: 15CENSUS: 14DATE:
03/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:33 AM
MET WITH:Administrator Bienafe PayuyoTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met with Administrator Bienafe Payuyo at approximately 9:30 AM and explained reason for visit.

Facility is licensed to serve clients 18 to 59 years old. There are fourteen (14) level 2 developmentally disabled clients residing at this facility. Clients at this facility are receiving services from Frank D Lanterman Regional Center. The Facility is a two-story building located in a residential area with nine (9) client bedrooms, four (4) shared bathrooms, living room, kitchen, dining room, front yard, backyard and detached car garage, and separate staff living cottage.

LPA Gutierrez arrived, and all doors were open, and house was at 58 degrees Administrator turned heater on to 74 degrees. LPA observed client bedrooms to have the required furniture, sufficient lighting, and closet/storage space. Bedroom # 9 had a ripped screen that needs to be repaired. Client bathrooms and shower rooms are equipped with required grab bars and non-skid mats. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The facility has two kitchens sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. During tour LPA observed scissors in unlocked drawer in kitchen. Fire extinguishers were observed throughout, with current inspections and were fully charged. Sharps and cleaning supplies/toxins were observed to be locked and inaccessible to clients in locked cabinet outside. The facility is equipped with surveillance cameras in common areas. There is a shaded seating area for the clients outside. Passageways and exits are free of obstruction.

SEE LIC 809C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
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.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 03/12/2025 02:28 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 03/11/2025 at 11:43 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SERRANO HOME CARE SERVICES, INC.
FACILITY NUMBER: 198600316

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above during tour of kitchen a pair of scissors were in unlocked cabinet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2025
Plan of Correction
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Administartor removed scissors and will conduct training with staff and send training log to LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/12/2025 02:28 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 03/11/2025 at 11:43 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SERRANO HOME CARE SERVICES, INC.
FACILITY NUMBER: 198600316

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(a)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) The licensee shall maintain the temperature in rooms that clients occupy between a minimum of 68 degrees F (20 degrees C) and a maximum of 85 degrees F (30 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above staff had doors open during rain with no heater house was at 54 degrees which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2025
Plan of Correction
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Administrator turned heater on to 74 degrees and shut doors. Administrator will go over with staff the importance of keeping home at minimum required temperature.
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above room number 9 had a ripped screen door which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2025
Plan of Correction
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Administartor will replace or fix ripped screen door and send LPA pictures by POC due date.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


LIC809 (FAS) - (06/04)
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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SERRANO HOME CARE SERVICES, INC.
FACILITY NUMBER: 198600316
VISIT DATE: 03/11/2025
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Five (5) staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Five (5) clients files were reviewed and included physicians report, TB clearance, and appraisal needs and service plan. Last fire/earthquake drill was conducted in February of 2025. Infectious control plan was reviewed. Three (3) staff and three (3) clients were interviewed. Clients’ medications were reviewed. Medications are centrally stored and locked MAR log is used.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809Ds. Exit interview held and a copy of the report along with appeal rights were provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
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
LIC809 (FAS) - (06/04)
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