197608195-1-26-2024-31-AS-MVAO-CZYW3F-20240130155552

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608195
Report Date: 01/26/2024
Date Signed: 01/26/2024 04:36:42 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/24/2024 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20240124091144

FACILITY NAME:	PALMDALE SENIOR VILLA, LLC		FACILITY NUMBER:	197608195
ADMINISTRATOR:	JOJOMAURELI B. SALAMERO		FACILITY TYPE:	740
ADDRESS:	38719 37TH STREET EAST		TELEPHONE:	(661) 526-4394
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93550
CAPACITY:	6	CENSUS: 5	DATE:	01/26/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	JOJOMAURELI B. SALAMERO		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff are not ensuring that food is of good quality.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 01/26/2024 Licensing Program Analyst (LPA) Melissa Spaeth, initiated a complaint investigation for the allegation(s) listed above. LPA Spaeth was greeted by the Administrator. LPA Spaeth explained the purpose of the visit was to investigate a complaint.

LPA requested the following documents: 1) Resident roster; and 2) staff roster. LPA Spaeth received the documents during the visit. LPA and the Administrator toured the facility at 10:45 am until 11:15 am. LPA interviewed residents at 11:15 am until 11:45 am.

It was alleged that the milk in the facility refrigerator was expired and had been previously frozen. It was also reported that the milk is thrown away one week after it has been thawed but the facility did not track the dates to determine when the milk should be thawed.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 31-AS-20240124091144

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: PALMDALE SENIOR VILLA, LLC	FACILITY NUMBER: 197608195
	VISIT DATE: 01/26/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

At 10:45 am, LPA observed the expiration date for the milk within the refrigerator was 01/30/2024. At 10:55 am, LPA observed a gallon of milk was in the freezer. The expiration date was 1/30/2024. LPA observed the gallon contained an additional black marker reminder with the expiration date marked in large letters. The Administrator stated the milk will be used before the expiration date. The residents drink a gallon of milk every week. The Administrator stated milk is purchased every two weeks. LPA Spaeth observed there was no expired food within the pantry or the refrigerator.

LPA interviewed three of the four residents. Residents 1, 2, 3, and 4 unanimously agreed the food is good quality. Residents 1, 2, 3 and 4 stated the facility staff has never served spoiled milk or spoiled food. R5 was sleeping during LPA’s visit.

Based upon LPA Spaeth’s observations and interviews, the allegation, facility staff are not ensuring that food is of good quality is unsubstantiated.

Exit interview conducted and a copy of the report was given.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2