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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610251
Report Date: 06/01/2023
Date Signed: 06/01/2023 01:53:10 PM

Document Has Been Signed on 06/01/2023 01:53 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:MONDELL PINE MANOR IFACILITY NUMBER:
197610251
ADMINISTRATOR:SOLIS, CANDICEFACILITY TYPE:
740
ADDRESS:39046 MONDELL PINE AVETELEPHONE:
(805) 468-5068
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 6CENSUS: 4DATE:
06/01/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Cristina AquinoTIME COMPLETED:
02:00 PM
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LPA Spaeth conducted an unannounced visit on 6/01/2023 to conduct a complaint investigation regarding Complaint # 31-AS-20230525110238. LPA and Caregiver conducted a tour of the facility at 10:30 am until 10:50 am. At 10:30 am, LPA observed the knives were located in an unlocked kitchen cabinet. Caregiver stated the lock was broken and the lock needed to be replaced. LPA requested caregiver move the knives to a locked, secure location.

At 10:32 am, LPA observed caregiver locked the knives in a locked closet next to the kitchen area. At 10:45 am, the facility manager arrived at the facility. LPA explained the knives were not locked in a safe location and LPA observed caregiver moved the knives to a locked closet. The facility manager stated will ensure staff will make sure the knives are locked at all times.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency was cited (refer to LIC 809-D).

Exit interview conducted, Appeal Rights were given to the Facility Manager, and a copy of the signed report was given to the Office Manager.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/01/2023
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 06/01/2023 01:53 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 06/01/2023 at 01:27 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: MONDELL PINE MANOR I
FACILITY NUMBER: 197610251

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/01/2023
Section Cited
CCR
87705(f)(1)

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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches.. This requirement is not met as evidenced by:
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At 10: 32 am, LPA observed caregiver removed the knives from the unlocked kitchen cabinet and were moved to a locked closet.
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Based on LPA's observation, the licensee failed to ensure the knives were inaccessible to dementia residents which poses an immediate health and safety risk to residents 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.
SUPERVISOR'S NAME:Troy Agard
LICENSING EVALUATOR NAME:Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023


LIC809 (FAS) - (06/04)
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