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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802117
Report Date: 10/04/2024
Date Signed: 10/07/2024 08:26:59 AM


Document Has Been Signed on 10/07/2024 08:26 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:SERENE VILLA SENIOR CAREFACILITY NUMBER:
425802117
ADMINISTRATOR:BAUTISTA, SUNNYFACILITY TYPE:
740
ADDRESS:1935 NOROESTE AVETELEPHONE:
(805) 346-1950
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY:6CENSUS: 0DATE:
10/04/2024
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:NATIME COMPLETED:
02:37 PM
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CCL received email from licensee/administrator Sunny Bautista stating they have no residents as of June 26, 2024. Licensee subsequently advised Regional Office, of their intent to close the facility effective October 1, 2024.

Licensing Program Analyst (LPA) Erika Miller arrived unannounced to conduct a unannounced closure visit.


LPA rang the doorbell, called licensee and left a voicemail, and left a business card at the door at 10:15 a.m. Licensee did not return phone. LPA returned to facility at 2:30 p.m. rang door bell and no one answered the door.

LPA observed the exterior of the facility and did not note any hazards, or evidence of facility in operation. No voices heard and shutters were closed. The RO will close out the facility as of 10/1/2024.
Report emailed.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika MillerTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2024
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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