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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610251
Report Date: 11/15/2023
Date Signed: 11/15/2023 11:51:20 AM

Document Has Been Signed on 11/15/2023 11:51 AM - 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: 0DATE:
11/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Stephanie DomingoTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced annual visit, knocked on the door, and no one answered. LPA Spaeth called the facility phone and spoke to the Administrator Stephanie Domingo of the Mondell Pine Manor II. The Administrator stated there are no residents living at the facility. The Administrator confirmed there were three residents in which two residents passed away and one moved out three months ago. The Administrator met LPA at 9:30 am.

LPA and the Administrator began the tour of the facility at 9:35 am until 10:00 am. LPA observed the three residents' rooms were still furnished with a bed, linens, lamp, night stand, and chair. LPA observed there were no residents in each room. The bathrooms were neat and clean and contained hand soap, paper towels, slip resistant mats and grab bars.

LPA observed the common areas such as the dining room and family room still contained comfortable seating. LPA tested the smoke detector at 9:45 am.

The staff room contained furniture for live-in staff and observed there were no staff members living within the facility.

There are no deficiencies to report at this time. Exit interview was conducted and a copy of the report was given to the Administrator.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2023
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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