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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610251
Report Date: 05/14/2025
Date Signed: 05/14/2025 03:36:13 PM

Document Has Been Signed on 05/14/2025 03:36 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/
DIRECTOR:		SOLIS, CANDICEFACILITY TYPE:
740
ADDRESS:39046 MONDELL PINE AVETELEPHONE:
(805) 468-5068
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 6CENSUS: 3DATE:
05/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Richard GarciaTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by the facility manager, Richard Garcia. LPA stated the purpose of the visit was to conduct an annual inspection. The staff member confirmed there are three residents living in the facility. The facility is licensed for six (6) non-ambulatory residents of which one can be bedridden. The facility has a hospice care waiver for six residents.

LPA Spaeth reviewed the resident records and resident medications at 10:15 am until 11:10 am. LPA reviewed staff files at 11:10 am until 12:00 pm.

LPA and the Facility Manager toured the facility at 12:30 until 1:15 pm.

Delayed Egress - At 1:02 pm, LPA observed the delayed egress at the sliding glass door that leads to the backyard was not working. The Facility Manager stated the alarm had been turned off earlier today. The Facility Manager turned on the alarm at 1:05 pm.

Common Areas – The family room, dining room, and kitchen are combined. The family room is furnished with comfortable seating and a television. The dining room is furnished with a dining room table and chairs.

Medications: LPA observed the resident medications, first aid kit, and PPE supplies were safely locked in a hallway closet.

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Melissa Spaeth
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MONDELL PINE MANOR I
FACILITY NUMBER: 197610251
VISIT DATE: 05/14/2025
NARRATIVE
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Kitchen – LPA observed a two day supply of perishable food and a seven day supply of non-perishable food items. The fire extinguisher is located near the kitchen and was operable. The knives are locked in a kitchen drawer. Cleaning solutions are locked underneath the kitchen sink.

Laundry Room – The laundry room door has a key-punch lock system. LPA observed the washer/dryer and the laundry detergent were in the room and additional cleaning solutions

Garage-Staff Room –The door leading to the garage and the staff room was locked.

Resident Rooms: There are three resident rooms which were furnished with a bed, linens, night stand, lamp and chair. The rooms were neat and clean.

Bathrooms: There are two bathrooms in the facility. The bathrooms contained hand soap, paper towels, grab bars, and slip resistant mats. LPA observed clean linens.

Water Temperature: LPA tested the water temperature at 1:00 pm which was 113 degrees F.

Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. The side gate of the house was closed and was not locked. Comfortable seating is also located in the backyard.

Smoke/Carbon monoxide detector: The detector was operable as of 1:10 pm. .

Based upon LPA's observations and review of the resident/staff files, the following deficiencies were issued.

Exit interview conducted, appeal rights discussed, and a copy of the report was given.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Melissa Spaeth
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/14/2025 03:36 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 05/14/2025 at 01:29 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: 05/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two out of three staff members which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/16/2025
Plan of Correction
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The Administrator will send a snap shot to LPA's cell phone of the staff members' (S1 and S2) completion of the CPR/first aid training.
Type A
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the review of a staff's records, the licensee did not comply with the section cited above in one out of three staff members which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2025
Plan of Correction
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The Administrator will send a copy of the completed Health screening document for staff #1 to LPA Spaeth via email (melissa.spaeth@dss.ca.gov).
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Troy Agard
NAME OF LICENSING PROGRAM MANAGER:
Melissa Spaeth
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 05/14/2025 03:36 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 05/14/2025 at 01:29 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: 05/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff records review, the licensee did not comply with the section cited above in one out of three staff members which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/16/2025
Plan of Correction
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The Administrator will send a snapshot of staff #1's association to the facility to LPA's cell phone.
Type A
Section Cited
CCR
88705(k)
88705 Care of persons with Dementia (k) the following initial and continuing requirements must be met...to utilized delayed egress devices on exterior doors or perimeter fence gates.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above. LPA observed the delayed egress to the back door was turned off which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2025
Plan of Correction
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During LPA's visit, LPA observed the staff member turned on the delayed egress notification at 1:00 pm.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Troy Agard
NAME OF LICENSING PROGRAM MANAGER:
Melissa Spaeth
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2025


LIC809 (FAS) - (06/04)
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