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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610646
Report Date: 10/02/2024
Date Signed: 10/02/2024 12:21:12 PM

Document Has Been Signed on 10/02/2024 12:21 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:CLUB VISTA CARE HOMEFACILITY NUMBER:
197610646
ADMINISTRATOR/
DIRECTOR:		SAMANIEGO, JOHN ROELFACILITY TYPE:
740
ADDRESS:4212 CLUB VISTA DRIVETELEPHONE:
(661) 794-9940
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 6CENSUS: DATE:
10/02/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:John SamaniegoTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 10/02/2024, Licensing Program Analyst (LPA) Melissa Spaeth conducted an announced Pre-Licensing visit to this facility and met with the Licensee John Samaniego. This is a new application and a fire clearance dated 6/28/2024 was received for one ambulatory, four non-ambulatory and one bedridden residents for a total of six residents. The purpose of today’s visit is to inspect the facility to ensure that it maintains compliance under California Code of Regulations, Title 22, Division 6

Today’s site visit consisted of LPA conducting the Comp III presentation at 9:15 am until 10:00 am and touring the physical plant inside and outside from 10:00 am until 10:30 am. LPA Spaeth observed the following:

Common Area – LPA observed the living room, dining room, and kitchen are combined. The living room area contains comfortable seating. The dining room area contained dining room table, chairs, and a locked cabinet to store resident and staff files. The kitchen area contained a seven day supply of non-perishable food and a two day supply of perishable foods. A locked kitchen cabinet contained resident medication containers and the first aid kit. The cabinet underneath the kitchen sink was locked. There is a locked drawer for knives. A fire extinguisher is also located in the kitchen. A pantry is located in the kitchen area.

Backyard - The back yard contained a shaded seating area overlooking the golf course. The side gate leading from the backyard to the front yard was not locked.

Bedrooms - There are five bedrooms which contained bed, linens, night stand, lamp, chest of drawers, and a chair.

Bathrooms - There are three bathrooms which contained a walk in shower, grab bars, hand soap, paper towels, trash can, and slip resistant mats.

Continued on 809-C
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.

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: CLUB VISTA CARE HOME
FACILITY NUMBER: 197610646
VISIT DATE: 10/02/2024
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Water Temperature - LPA tested the water temperature at 10:30 am and the temperature was 110.0 degrees F.

Staff room- The staff room contained a bed.

The smoke and carbon monoxide detectors were tested at 10:20 am and were operable. The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all exit doors. The facility was clean and appears to be in good repair.

The Licensee stated the facility phone number is 661-480-0321.

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 Licensee. A copy of this 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
LIC809 (FAS) - (06/04)
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