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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608195
Report Date: 01/26/2024
Date Signed: 01/26/2024 04:35:07 PM

Document Has Been Signed on 01/26/2024 04:35 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: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:
01/26/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:JOJOMAURELI B. SALAMEROTIME COMPLETED:
02:30 PM
NARRATIVE
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On 1/26/2024, Licensing Program Analyst (LPA), Melissa Spaeth conducted an unannounced complaint visit regarding Complaint #31-AS-20240124091144. During the visit, LPA observed a caregiver working at the facility who had not obtained a California clearance or a criminal record clearance. The Administrator stated the individual was shadowing the Administrator but had not obtained the required clearance.

Per CA Code of Regulations, Title 22, the following deficiencies were issued (See 9099-D).

Exit interview conducted, appeal rights discussed, 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
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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Document Has Been Signed on 01/26/2024 04:35 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 01/26/2024 at 01:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PALMDALE SENIOR VILLA, LLC
FACILITY NUMBER: 197608195

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/26/2024
Section Cited
CCR
87411(g)(1)

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87411 Personnel Requirements – General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to criminal record review shall: (1) Obtain a California clearance or a criminal record exemption as required by law….This requirement is not met as evidenced by:
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LPA observed unknown person who is not associated in the facility. LPA is also unable to identify if the person has Criminal record clearance. LPA observed the person immediately left the facilty to obtain the clearance.

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Based on LPA's observations, an individual was present who had not cleared the criminal record clearance. This poses an immediate health & safety risk to the residents in care.

$100 civil penalty has been assesed during this
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Troy Agard
LICENSING EVALUATOR NAME:Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024


LIC809 (FAS) - (06/04)
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