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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610251
Report Date: 06/02/2022
Date Signed: 06/02/2022 03:11:50 PM

Document Has Been Signed on 06/02/2022 03:11 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:MONDELL PINE MANOR IFACILITY NUMBER:
197610251
ADMINISTRATOR:SOLIS, CANDICEFACILITY TYPE:
740
ADDRESS:39046 MONDELL PINE AVE.TELEPHONE:
(818) 332-6150
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 6CENSUS: 0DATE:
06/02/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Candice SolisTIME COMPLETED:
12:30 PM
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LPA Spaeth conducted a pre-licensing visit to the facility and was greeted by the Administrator Candice Solis and four staff members at 9:10 am. LPA observed all parties were wearing masks. LPA's temperature was taken and recorded at the sign-in station at the front door. LPA was instructed to complete the sign in sheet and answer the required COVID symptoms questions.

LPA conducted the Comp III session from 9:15 am until 10:20 am. The tour of the facility took place from 10:30 am until 11:00 am. LPA observed the living room-kitchen combination. The living room contained comfortable seating along with a television. LPA observed a three-day supply of perishable fruits and vegetables in the refrigerator and an adequate supply of frozen meats and vegetables in the freezer section. The cleaning supplies were locked underneath the sink and the knives were locked in a kitchen cabinet.

The pantry contained a seven day supply of non-perishable items such as canned goods, rice, and pasta. Also the emergency food and water supplies were located in the pantry. LPA also observed the menu posted within the facility. At 10:51 am, LPA observed the water temperature in the kitchen was 117.4 degrees F. LPA also observed the menu was posted in the facility.

LPA was escorted through a locked door to the stairway that leads to the staff room on the second floor and the locked garage. LPA observed two rooms on the second floor and a staff bathroom. Administrator confirmed there will not be any live in staff. Also, LPA observed the garage which contained some stored items.

LPA then observed the backyard which is neat and clean. Administrator stated lawn furniture will be arriving to the facility this month. LPA requested an email notification along with a snapshot of the furniture upon arrival to the facility. The side gate was unlocked that leads to the front yard.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2022
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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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: MONDELL PINE MANOR I
FACILITY NUMBER: 197610251
VISIT DATE: 06/02/2022
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LPA observed a locked closet which is the location for the resident medications. The first aid kit and an adequate supply of PPE was stored in the closet. LPA observed the three resident rooms contained the required bed, night stand, lamp, linens, closet for storage, and mattress.

There are two resident bathrooms in the facility which contained wash your hands sign, hand soap, paper towels, and trash can The bathrooms also contained grab bars and slip resistant mats in both showers. LPA observed the laundry room and LPA observed the laundry detergent was safely locked in the room. An additional supply of bed linens, blankets and towels were located in the laundry room.

LPA observed the Let Us Know sign and activities schedule was also located on a board at the front entrance.. The smoke and carbon monoxide detectors were checked at 10:49 am.

There are no deficiencies to report at this time. Exit interview conducted, appeal rights discussed, and a copy of the signed report was given to the Administrator.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC809 (FAS) - (06/04)
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