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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610286
Report Date: 03/26/2025
Date Signed: 03/26/2025 07:45:58 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
03/10/2025 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20250310120255
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: 83DATE:
03/26/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Stuart MontalvoTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff charged resident for services not rendered
Staff did not ensure that resident's incontinence care needs were met
INVESTIGATION FINDINGS:
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On 3/26/2025 Licensing Program Analyst (LPA) Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth met with the Administrator, Stuart Montalvo. LPA explained the purpose of this visit was to review documentation, conduct interviews and deliver the findings.

LPA Spaeth toured the facility at 10:00 am until 10:20 am. LPA interviewed nine (9) out of eighty-three residents at 10:45 am until 11:30 am. LPA also interviewed nine (9) out of forty-five staff members at 11:30 am until 3:00 pm. LPA reviewed residents’ records at 3:00 pm until 3:30 pm. LPA received copies of the Admissions Agreement, End of Shift Report, Billing Statement, Resident Move Out Form, Physician’s Report (LIC 602), Resident Assessment, and Needs and Services Plan.
Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025
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-20250310120255
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: 03/26/2025
NARRATIVE
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Regarding the allegation: Staff charged resident for services not rendered. It’s alleged a resident was charged for services not received but the resident was billed for those services. During interviews with staff, S1-S9 unanimously confirmed the resident was provided with escort services to the bathroom and dining room. S1-S9 also confirmed a daily report is completed by staff which states how staff assist residents in care. LPA reviewed the resident End of Shift Report for R1 and observed staff did escort the resident to the bathroom and to the dining room. The Administrator, Stuart Montalvo stated the resident received a full refund for the care provided from February 24, 2025 until March 2, 2025. LPA Spaeth reviewed the Billing Statement which confirms the resident did receive the refund and LPA confirmed the refund was received.

Regarding the allegation: Staff did not ensure that resident's incontinence care needs were met. It’s alleged a resident was not escorted to the bathroom. The Administrator and Jeisy Pinoargot, the Resident Care Director both confirmed the Needs and Services Plan is completed and presented to the resident and the family members prior to the move in date. LPA Spaeth reviewed the resident’s Needs and Services Plan and observed the resident would receive the recommended services. S1-S9 confirmed they provide the escort services to the residents in care. R2-R8 confirmed staff provide the incontinent services they need and also receive an escort to the bathroom. LPA Spaeth attempted to interview R1 but was unable due to their cognitive ability.

Based upon interviews conducted and the review of resident documentation, the allegations are unsubstantiated.

Exit interview conducted and a copy of the report was given.

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

DATE: 03/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2