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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608975
Report Date: 07/02/2025
Date Signed: 07/02/2025 11:43:18 AM

Document Has Been Signed on 07/02/2025 11:43 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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:MY SERENITY BOARD AND CAREFACILITY NUMBER:
197608975
ADMINISTRATOR/
DIRECTOR:		MASTOV, ELLAFACILITY TYPE:
740
ADDRESS:6658 CAPISTRANO AVETELEPHONE:
(747) 242-1916
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY: 6CENSUS: 5DATE:
07/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Gayane GrigorianTIME VISIT/
INSPECTION COMPLETED:
11:50 PM
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At 8:45 a.m. on 07/02/2025, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and later the administrator and disclosed the reason for the visit. LPA and the adinistrator toured the facility inside and out.

The facility was last visited on 06/14/24 for an annual visit. It is a single story building with five (05) bedrooms, four (04) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for six (06) residents, of which five (05) may be nonambulatory and one (01) bedridden. The facility serves residents with dementia. Approved hospice waivers for six (06).

At the main entrance, LPA observed postings for the facility’s visitation policy, emergency disaster plan, facility sketch and license, personal rights, and blank copy of the admission agreement. Additional postings were observed inside for confidential complaint contacts, emergency contacts, rights of resident councils, and ombudsman contacts. A screening station at the front contained a visitor log. Walls, floors, windows, screens, and blinds were clean and in good repair. At 9:00 a.m. LPA measured the room temperature to be 75 degrees Fahrenheit. At approximately 9:25 a.m., smoke and carbon monoxide detectors were tested and operational. At approximately 9:30 a.m. the licensee called the house telephone, which was deemed to be operational. At 9:35 a.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last inspected on 05/07/25 and had a tag attached. Five (05) out of five (05) residents were observed participating in activities in the living room together. Interview with the administrator at 9:45 a.m. today revealed the facility hired an activity coordinator who comes twice a week and a musician who comes once a week. The living room also contained a piano, musical equipment, reading material, art supplies, and exercise equipment. Hallway closets had board games, puzzles, and art supplies, PPE, and an adequate supply of fresh linens. Night lights were hung throughout the hallways.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
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: 07/02/2025
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The facility had five (05) bedrooms. The bedroom nearest the main entrance is designated as a staff room. The staff room was locked and free of hazards. Of the four (04) resident bedrooms, two (02) are shared and two (02) are private. Bedroom #2 and Bedroom #4 had appropriate signs stating “No smoking – Oxygen in use”. Bedroom #3 and Bedroom #4 had private bathrooms. All bedrooms contained a chair, lamp, nightstand, storage, activity calnedars, call buttons, and a bed with adequate bedding. All furnishings were clean and in good condition. At approximately 10:00 a.m. the call button in Bedroom #1 was tested and deemed operational.

The facility has four (04) bathrooms. Staff use the large bathroom nearest the main entrance to assist with bathing residents. All bathrooms contained liquid soap, paper towels, trash cans with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. Commodes and shower chairs were also available. At approximately 10:15 a.m. LPA measured the water temperature to be within regulatory range.

LPA observed an adequate supply of perishable and non-perishable foods in the kitchen. Appliances were in good condition. The administrator noted the microwave was promptly fixed after last year’s annual inspection. Cleaning solutions were locked below the sink and in a separate cabinet near the staff room. Sharps were locked in a lock box below the counter top. Medications were locked in a cabinet near the refrigerator. At approximately 10:30 a.m. a medication review was performed for three (03) residents. All medications were stored in the correct quantities.

A washing machine and dryer were located outside of the kitchen. Both were in working order. Detergents were locked in a storage container next to the appliances. LPA observed a covered, shaded patio area in the rear of the facility. The patio contained furniture in good condition. Ramps were secure and had sturdy hand rails. Ramps led out from the living room and Bedroom #3. The emergency exit path was free from tripping hazards. There was a locked storage shed with gardening supplies. The pool was fenced, locked, and inaccessible. The exit gate was unlocked with a self-closing, inward facing latch. Evacuation routes were posted. Four (04) out of four (04) auditory alarms were turned on and functioning.

At 10:45 a.m. LPA reviewed resident and personnel files. Files were complete and available for audit.

During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed.

Exit interview conducted. Copy of report provided.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
LIC809 (FAS) - (06/04)
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