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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610286
Report Date: 10/02/2024
Date Signed: 10/02/2024 04:34:15 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/25/2024 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20240925121504
FACILITY NAME:PALM VISTA SENIOR LIVINGFACILITY NUMBER:
197610286
ADMINISTRATOR:MONTALVO, STUARTFACILITY TYPE:
740
ADDRESS:3850 WEST RANCHO VISTA BLVDTELEPHONE:
(661) 202-3999
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:115CENSUS: 84DATE:
10/02/2024
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Stuart MontalvoTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff are not allowing resident to leave the facility
INVESTIGATION FINDINGS:
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On 10/02/2024, Licensing Program Analyst (LPA) Melissa Spaeth initiated a complaint investigation for the allegation(s) listed above. LPA was greeted by the Administrator, Stuart Montalvo. LPA Spaeth explained the purpose of this visit is to interview staff, a resident and gather information regarding the complaint allegation(s).

LPA Spaeth interviewed two staff members at 10:40 am until 11:00 am. LPA reviewed the residents' files at 12:15 until 12:45 pm. LPA received copies of the resident's documentation. LPA interviewed a resident at 12:30 pm until 1:00 pm. LPA Spaeth also toured the facility at 2:00 pm until 2:20 pm.

Regarding the allegation: Staff are not allowing resident to leave the facility. It’s alleged a resident (R1) had a friend who requested to take R1 on 9/11/2024 to a local location for a walk; however, the facility staff called R1’s POA. The POA stated R1 could not accompany the friend on an outing.
Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 31-AS-20240925121504
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: PALM VISTA SENIOR LIVING
FACILITY NUMBER: 197610286
VISIT DATE: 10/02/2024
NARRATIVE
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The Memory Care Director and the Administrator both confirmed the POA was contacted on 9/11/2024 regarding a friend’s request to take R1 out of the facility. The POA stated the friend could visit R1 in the facility but did not want R1 to leave. Due to R1’s cognitive ability, the POA wanted to ensure R1’s safety. LPA Spaeth attempted to interview R1; however, R1 was unable to recall the incident.

Based upon LPA’s interviews, the allegation is unsubstantiated.

An exit interview was conducted and a copy of the report was given.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
LIC9099 (FAS) - (06/04)
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