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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608195
Report Date: 05/29/2024
Date Signed: 05/29/2024 02:47:31 PM

Document Has Been Signed on 05/29/2024 02:47 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/
DIRECTOR:		JOJOMAURELI B. SALAMEROFACILITY TYPE:
740
ADDRESS:38719 37TH STREET EASTTELEPHONE:
(661) 526-4394
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 6CENSUS: 5DATE:
05/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:JOJOMAURELI B. SALAMEROTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Spaeth conducted an unannounced visit and was greeted by the caregiver. The Administrator was called and arrived at 10:00 am. LPA stated the purpose of the visit is to conduct an annual inspection. The facility is licensed for five non-ambulatory residents and one bedridden resident. LPA confirmed there are five residents in the facility.

LPA and the Administrator toured the facility at 10:00 am until 10:30 am.

Kitchen - The refrigerator was dirty and LPA explained the appliance needs to be clean at all times. LPA did not observe an adequate supply of perishable and non-perishable food.

Common Areas –The living room and dining room are combined and contained comfortable seating along with dining room table and chairs. The family room contained comfortable seating and a television.

Residents’ Rooms – The rooms contained a bed, linens, night stand, lamp, chest of drawers and a closet.

Bathroom – The bathroom contained grab bars, slip resistant mats, paper towels and a covered trash can. The water temperature was tested at 10:15 am and was 121.1 degrees F.

Backyard –The backyard contained comfortable seating. The gate leading from the backyard to the front yard was not locked.

Medications - The medications were locked in a cabinet located in the living room. The first aid kit was also locked in the cabinet.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2024
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 5
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: PALMDALE SENIOR VILLA, LLC
FACILITY NUMBER: 197608195
VISIT DATE: 05/29/2024
NARRATIVE
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Laundry Area – The washer and dryer are located in a laundry area. The laundry detergent was located in the locked garage.

Egress System -LPA Spaeth observed the egress system was working when exiting the facility.

Smoke/Carbon Monoxide Detectors - The smoke/carbon monoxide detectors were tested at 10:30 am and were properly working.


Residents’ Records -LPA reviewed residents' records at 10:30 am until 11:00 am and LPA did not observe any issues with the records.

Staff Records - LPA reviewed five staff records at 1:15 pm until 2:15 pm.

Based upon LPA's observations, the following deficiencies were cited (see 809-D page).

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: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 05/29/2024 02:47 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 05/29/2024 at 11:45 AM
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: 05/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on LPA checking the water temperatures, the licensee did not comply with the section cited above in which the water temperature tested at 10:30 am and was 121.1 Degress F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2024
Plan of Correction
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4
During LPA's visit, the water temperature was adjusted and was tested at 11:45 am. The water temperature was 118.00 degrees F.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on the LPA's observations, the staff room was unlocked and contained medication which was sitting out within the room, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2024
Plan of Correction
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4
During LPA's visit, the room was locked by the caregiver at 10:25 am.
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: 05/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/29/2024 02:47 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 05/29/2024 at 11:45 AM
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: 05/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on LPA's review of the staff records, S1 and S2 did not have the required CPR/first aid training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2024
Plan of Correction
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S1 and S1 will complete the CPR/First aid training. The Administrator will send a snapshot of S1's and S2's completion of the CPR/First aid training.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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3
4
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: 05/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 05/29/2024 02:47 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 05/29/2024 at 11:46 AM
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: 05/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations, the refrigerator was not clean which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2024
Plan of Correction
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LPA Spaeth observed the refrigerator was cleaned by the caregiver at 12:00 pm.
Type B
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, there was not a one week supply of nonperishable foods and not an adequate supply of a two day supply of perishable foods which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2024
Plan of Correction
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The Administrator will purchase a one week supply of nonperishable foods and a two day supply of perishable foods and send a snapshot of the food purchased. The Administrator will send the snapshot to LPA Spaeth as of 5/30/2024.
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: 05/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024


LIC809 (FAS) - (06/04)
Page: 5 of 5