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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610326
Report Date: 01/31/2023
Date Signed: 01/31/2023 12:25:40 PM

Document Has Been Signed on 01/31/2023 12:25 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:MONDELL PINE MANOR IIFACILITY NUMBER:
197610326
ADMINISTRATOR:VIRAY, JEROMEFACILITY TYPE:
740
ADDRESS:39040 MONDELL PINE AVENUETELEPHONE:
(818) 332-6150
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 6CENSUS: 0DATE:
01/31/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Jerome Viray, Adminstrator. TIME COMPLETED:
01:00 PM
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At 10:45am Licensing Program Analysts (LPA) Angela Panushkina conducted an announced Pre-Licensing visit to the above facility and met with applicant Mondell Pine Manor II, Inc. LPA conducted an entrance interview with the Administrator.

Fire Clearance dated 09/23/2022 was received for four non-ambulatory, (2) bedridden and six (6) hospice residents. The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. The facility is a single-story building. Today's site visit consisted of LPA touring the physical plant inside and outside and observed the following:

The facility has a total of four (4) bedrooms, four (4) of which are designated for resident use. Resident bedrooms were observed to be appropriately furnished. There are two (2) and half bathrooms in the facility designated for resident use and were observed to have non-skid mats and appropriate grab bars installed. The facility will have awake staff at night.

The common areas (living room, kitchen and dining areas) were appropriately furnished and lighting was adequate. The living room has a television and comfortable furniture. Two (2) fire extinguishers were purchased on 01/12/2023. LPA observed one (1) fire extinguisher by the entrance door and one (1) fire extinguisher located in the kitchen. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 11:30am they were tested and observed to be operational. At 11:40am the hot water was tested and measured at 119.0°F. There is a functioning telephone on the premises. An emergency exit plan/sketch is posted by the entrance. Medications, residents and staff records will be stored in a locked cabinet in the hallway. The first aid kit is readily available. The kitchen knives are stored in a locked kitchen cabinet. LPA also observed cleaning solution and soap kept locked and stored underneath the kitchen sink.

Continue on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MONDELL PINE MANOR II
FACILITY NUMBER: 197610326
VISIT DATE: 01/31/2023
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The laundry area is located in a hallway by the garage and all detergents, cleaning supplies and other toxins will be kept locked. The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all doors and locked areas for centrally stored medications. Facility appears to be clean and in good repair. Appliances in the kitchen appeared to be functional.

There is a sitting area in the backyard for residents to conduct outdoor activities. The backyard is fenced. There is no body of water in the facility.

Component III was conducted with the Administrator.

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.

Exit interview was conducted with the Administrator and a copy of this report was provided.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023
LIC809 (FAS) - (06/04)
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