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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608195
Report Date: 10/25/2024
Date Signed: 11/20/2024 03:21:22 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
09/15/2023 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20230915113421
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:
10/25/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Genevieve BalanayTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff does not dispose deceased resident's medications.
Staff does not ensure resident's ingest medications.
Residents have access to a lighter.
Residents have access to scissors and knives.
INVESTIGATION FINDINGS:
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This is an amended copy of the report previously issued on 10/25/2024. This report supersedes reports previously issued. The findings for this complaint remain the same.

On 10/25/2024 Licensing Program Analyst (LPA) Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth was met by the caregiver. The Administrator was called and LPA explained the purpose of the visit was to interview the residents and present the findings. The Administrator stated the caregiver may sign the report.

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
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 4
Control Number 31-AS-20230915113421
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: 10/25/2024
NARRATIVE
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This is an amended copy of the report previously issued on 10/25/2024. This report supersedes reports previously issued. The findings for this complaint remain the same.

LPA conducted a physical tour at 10:15 until 10:30 am. LPA interviewed four out of the five residents at 10:30 am until 11:15 am. The investigation consisted of the following: On 9/21/2023 LPA Spaeth initiated a complaint investigation for the allegation(s) listed above. LPA Spaeth toured the facility at 2:15 am until 2:30 pm and interviewed the Administrator at 3:00 pm.

Regarding the allegation: Staff does not dispose deceased resident's medications: it’s being alleged a deceased resident’s medication was in an unlocked cabinet and was not properly disposed by staff. On 9/21/2023 at 2:30 pm, LPA did not observe a deceased resident’s medication stored in an unlocked kitchen cabinet.

Regarding the allegation: Staff does not ensure resident's ingest medications. It’s being alleged that staff did not observe residents taking their medication. LPA Spaeth interviewed the Administrator and staff member (S1) on 9/21/2024. The Administrator and S1 confirmed when distributing resident’s medications, they both observe residents taking their medications. LPA Spaeth interviewed four out of the five residents. The four residents interviewed (R1, R2, R3 and R4) unanimously confirmed staff observe them taking their medication. R4 was unavailable.

Regarding the allegation: Residents have access to a lighter: it’s being alleged that a lighter was stored in an unlocked cabinet. During LPA’s tour of the facility on 9/21/2023, LPA did not observe a lighter stored in an unlocked cabinet.

Regarding the allegation: Residents have access to scissors and knives: it’s being alleged that a knife and scissors were stored in an unlocked drawer. During LPA’s tour of the facility on 9/21/2023, LPA did not observe such items in an unlocked cabinet.

Based upon LPA's observations, the above allegations are 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: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4
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
09/15/2023 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20230915113421

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:
10/25/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:TIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
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5
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9
Staff does not securely lock resident's medications.
INVESTIGATION FINDINGS:
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Regarding the allegation: Staff does not securely lock resident's medications: it’s being alleged that a resident’s medication was not securely stored in the refrigerator. During LPA’s tour of the facility on 9/21/2023 at 2:25 pm, LPA observed a resident’s medication was in the refrigerator and was not securely locked.

Based upon LPA's observation, the allegation is substantiated.

Exit interview conducted, appeal rights discussed, and a copy of the report was given.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20230915113421
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/25/2024
Section Cited
CCR
87465(h)(2)
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87465 Incidental Medical & Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe & locked place…This is evidenced by:
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The Licensee purchased a locked drawer safe. The medication was locked in the drawer safe and placed in the refrigerator.
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Based on LPA's observation, the licensee failed to ensure a resident's medication was locked in the refrigerator which poses an immediate health and safety risk to persons in care.
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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.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4