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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610251
Report Date: 06/12/2024
Date Signed: 06/12/2024 11:32:33 AM

Document Has Been Signed on 06/12/2024 11:32 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/
DIRECTOR:		SOLIS, CANDICEFACILITY TYPE:
740
ADDRESS:39046 MONDELL PINE AVETELEPHONE:
(805) 468-5068
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 6CENSUS: 0DATE:
06/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Stephanie DomingoTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced annual visit and was greeted by the Administrator, Stephanie Domingo. LPA Spaeth stated the purpose of the visit was to complete an annual inspection. The Administrator stated there are no residents living at the facility. During LPA Spaeth's last annual inspection on 11/15/2023, LPA Spaeth toured the facility with the Administrator and did not observe residents in the facility.

LPA and the Administrator began the tour of the facility at 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 also observed the garage was empty. LPA tested the smoke detector at 10:15 am and observed the detectors were operable.

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: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2024
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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