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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608195
Report Date: 04/08/2022
Date Signed: 04/08/2022 11:21:43 AM

Document Has Been Signed on 04/08/2022 11:21 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:PALMDALE SENIOR VILLA, LLCFACILITY NUMBER:
197608195
ADMINISTRATOR:JOJOMAURELI B. SALAMEROFACILITY TYPE:
740
ADDRESS:38719 37TH STREET EASTTELEPHONE:
(661) 526-4394
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 6CENSUS: 5DATE:
04/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:JOJOMAURELI SALAMERO, ADMINISTRATORTIME COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA) Shira Stamps met with Administrator Jojomaureli Salamero for an unannounced one (1) year Required visit for this facility. LPA arrived at 10:08 am and was greeted by the Administrator. LPA informed the Administrator of the purpose of the visit. Entrance interview conducted.

Infection control: LPA reviewed the facility mitigation plan (approved on 06/02/21) to make sure the licensee was following current infection control recommendations. Upon arrival LPA was properly screened by the Administrator.

A tour of the physical plant was conducted with the Administrator at 10:21 am. The facility has five (5) bedrooms and two (2) bathrooms currently occupying five (5) residents. One (1) bedroom is designated for staff use only. Two residents were observed watching tv in the family, and the other residents were observed in their rooms.

Living and dining
At 10:21 am, LPA observed the living room and family room area to be neat and clean along with the dining room. LPA observed the locked medication cabinet located in the family room. The facility maintains a comfortable temperature at 76°F. The smoke detector and dual carbon monoxide detectors were tested and observed to be operational at 10:35 am. There is one (1) fire extinguisher located in the kitchen. The fire extinguisher was observed to be full and last serviced on 04/28/22.

CONTINUED...
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PALMDALE SENIOR VILLA, LLC
FACILITY NUMBER: 197608195
VISIT DATE: 04/08/2022
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Food Inspection
LPA conducted a tour of the kitchen around 10:23 am and observed a supply of seven day non-perishable and two day perishable foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas care clean and inaccessible to pests. Cleaning supplies, pesticides, detergents and/or toxins are stored in the cabinet below the kitchen sink and were locked and inaccessible to residents. Knives and sharps are also locked in a kitchen drawer.

Bathrooms
At 10:24 am LPA observed all bathrooms to have non-skid matts and the appropriated wash your hands signs posted in the bathroom. Hot water was tested and measured within regulation at 113.3 degrees F.

Resident Rooms
At 10:25 am, LPA observed rooms to have the appropriate bedding. There is a nightstand and sufficient lighting for each resident. The staff room remains locked and inaccessible to residents in care.

Laundry
At 10:29 am, LPA observed the laundry area located in the hallway near the garage. LPA observed extra liens in a cabinet located in the hallway.

Garage
At 10:30am, LPA observed the attached garage, used for storage, 30-day supply of PPE, chemicals/toxins, and an extra freezer. The garage is locked at all times, and residents do not have access.

Physical environment
LPA toured the outside area of the facility at 10:32 am. LPA observed appropriate outdoor furniture. There are no bodies of water on the premises. All door alarms are functional.

Administrative: Annual fee is current.

An exit interview was conducted, and a copy of this report and appeal rights were given to the Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
LIC809 (FAS) - (06/04)
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