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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610663
Report Date: 10/16/2024
Date Signed: 10/16/2024 01:23:43 PM

Document Has Been Signed on 10/16/2024 01:23 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:SERENE HAVEN ASSISTED LIVINGFACILITY NUMBER:
197610663
ADMINISTRATOR/
DIRECTOR:		PARYAV, SINTIAFACILITY TYPE:
740
ADDRESS:22445 VANOWEN STTELEPHONE:
(818) 457-0197
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY: 6CENSUS: 0DATE:
10/16/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Sintia ParyavTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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At 10:00 a.m. on 10/16/24, Licensing Program Analyst (LPA) Nicholas Reed conducted an announced prelicensing inspection. LPA met with the licensee and disclosed the reason for the visit. LPA and the licensee toured the facility inside and out at 10:10 a.m.

Today's prelicensing inspection is an initial application with no residents in care. The facility is a single story building with six (06) bedrooms, three (03) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents, of which one (01) may be bedridden in Bedroom #3. The facility plans to serve residents with dementia. Approved hospice waivers for five (05).

The front entrance is gated and unlocked. Fruit bearing trees were observed in the front and back yards. Both yards were maintained. Shaded seating areas were observed at the front and rear of the facility as well. At the front door, LPA observed postings for the facility sketch, administrator certificate, emergency disaster plan, personal rights, theft and loss policy, rights of resident councils, nondiscrimination notice, confidential complaint contacts, and ombudsman contacts.

Walls, floors, windows, screens, and blinds were clean and in good repair. At 10:15 a.m. LPA measured the room temperature to be 72 degrees Fahrenheit. The living room contained a television, reading materials, board games, puzzles, and furniture in good repair. A fireplace was appropriately covered. LPA also observed an office area near the main entrance. At 10:20 a.m. the house telephone was called and deemed operational. At 10:25 a.m., smoke and carbon monoxide detectors were tested and operational. Smoke detectors are hard-wired and functioned simultaneously. At approximately 10:30 a.m. LPA observed a fully charged fire extinguisher in the kitchen. It was purchased on 06/30/24. Hallways and resident rooms contained night lights and emergency flashlights. Hallway closets contained hygiene supplies, paper supplies, and adequate amounts of fresh linens.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
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 2
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: SERENE HAVEN ASSISTED LIVING
FACILITY NUMBER: 197610663
VISIT DATE: 10/16/2024
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LPA observed an adequate supply of perishable and non-perishable foods in the refrigerator, freezer, and pantry. The pantry also contained sufficient emergency food and water supplies. Appliances were clean and in good condition. Sharps were locked below the counter top. Cleaning solutions were locked below the sink. Medications and confidential files were locked in cabinets near the dining area. A washing machine and dryer were located near the kitchen. Both appliances were in working order. Detergents were locked below the sink.

Tour of the back yard revealed the main exit gate was unlocked. The rear exit gate near an alley way was unlocked from the inside as well. Exit paths were free of debris and tripping hazards. Ramps and hand rails were secure and sturdy. The pool in the back yard was gated, inaccessible, and locked in two (02) places. The garage was locked and contained extra supplies, tools, and an extra refrigerator.

The facility has six (06) bedrooms. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. Beds with wheels were locked and secured. Four (04) out of four (04) auditory alarms were tested and functioning.

The facility has three (03) bathrooms. Two (02) bathrooms are private to Bedrooms #3 and #6. The shared bathroom is located near Bedroom #1. All bathrooms contained paper towels, handwashing instruction sign, liquid soap, trash cans with tight fitting lids, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 10:45 a.m. LPA measured the water temperature to be 114.8 degrees Fahrenheit in the shared bathroom.

At 11:00 a.m. LPA and the licensee reviewed the Compliance and Regulatory Enforcement (CARE) tools and Component III.

Pre-Licensing is complete and this facility has no deficiencies.

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC809 (FAS) - (06/04)
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