197610326-1-9-2025-31-AS-MSPH-DCRVPS-20250109153711

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610326
Report Date: 01/09/2025
Date Signed: 01/09/2025 03:38:15 PM

Document Has Been Signed on 01/09/2025 03:38 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 II		FACILITY NUMBER:	197610326
ADMINISTRATOR/ DIRECTOR:	STEPHANIE DOMINGO		FACILITY TYPE:	740
ADDRESS:	39040 MONDELL PINE AVENUE		TELEPHONE:	(661) 480-5023
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY: 6		CENSUS: 2	DATE:	01/09/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Naylinda Sarapio		TIME VISIT/ INSPECTION COMPLETED:	01:15 PM

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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by the staff member. The Administrator Stephanie Domingo was called. LPA stated the purpose of the visit was to conduct an annual inspection. The staff member confirmed there are two residents living in the facility. The facility is licensed for six (6) non-ambulatory residents. Two (2) of the six (6) can be bedridden residents.

LPA Spaeth and the staff member toured the facility at 10:15 am until 11:00 am.

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 kitchen cabinet.

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 medications are locked in a cabinet and the knives are locked in a kitchen drawer. Cleaning solutions are locked underneath the kitchen sink.

Continued on 809-C

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MONDELL PINE MANOR II	FACILITY NUMBER: 197610326
	VISIT DATE: 01/09/2025

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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.

Garage –The garage was locked. The staff room is located within the garage area.

Resident Rooms: There are four resident rooms which were furnished with a bed, linens, night stand, lamp and chair. The rooms were neat and clean. LPA Spaeth observed the resident rooms contain a sprinkler system.

Bathrooms: There are three bathrooms in the facility. The bathrooms contained hand soap, paper towels, grab bars, and slip resistant mats. LPA observed the clean linens were located in a cabinet within the staff bathroom.

Water Temperature: LPA tested the water temperature which was 105 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 Detectors: The smoke/carbon monoxide detectors were tested at 11:20 am and were operable.

LPA reviewed resident files at 10:45 am until 11:10 am. LPA observed a resident's document was missing from the resident file. LPA reviewed staff's file at 11:20 until 11:30 am. LPA viewed a resident's medication at 11:30 until 11:45 am.

Based upon LPA's observations and upon Title 22 Regulations, the following deficiencies are substantiated. (See 809-D page).

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

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/09/2025 03:38 PM - It Cannot Be Edited

Created By: Melissa Spaeth On 01/09/2025 at 12:36 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 II	FACILITY NUMBER: 197610326
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87458(c)(1)(A)

Medical Assessment

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. The Administrator failed to obtain the communicable tuberculosis test results for R1 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/10/2025
	Plan of Correction
1 2 3 4	The Administrator will send the TB test results to LPA Spaeth via email.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Troy Agard

LICENSING EVALUATOR NAME:

Melissa Spaeth

LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

LIC809 (FAS) - (06/04)

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