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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610809
Report Date: 12/22/2025
Date Signed: 12/22/2025 12:09:47 PM

Document Has Been Signed on 12/22/2025 12:09 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:SAM'S PRESTIGE CAREFACILITY NUMBER:
197610809
ADMINISTRATOR/
DIRECTOR:		SALVADOR, DAVIDFACILITY TYPE:
740
ADDRESS:38433 ANSET DRIVETELEPHONE:
(661) 480-0303
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 6CENSUS: 4DATE:
12/22/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:David Salvador- AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 12/22/2025, at approximately 10:00 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an announced Pre-licensing visit. LPA met with Administrator, David Salvador.

An application for a change of ownership was submitted to Community Care Licensing Division (CCLD) on 03/07/2025, Initial license for a Residential Care Facility for the Elderly (RCFE), 60 years and older. The pending facility will have a Dementia Care Program. The requested capacity is for five (5) non-ambulatory and one (1) bedridden, total of up to six (6) residents. The fire clearance was approved on 05/09/2025. There are currently four (4) residents.

Structure: The facility is a single-story building with six (6) bedrooms and three (3) bathrooms. There is one (1) designated staff room only.

Entrance: There is only one (1) entrance being utilized. Required postings such as: Personal Rights of Residents, Rights of Resident by Council, Family Council, Infection Control, Emergency and Disaster Plan, Facility Sketch, Theft and Loss Policy, House Rules, Non-discrimination Policy and See Something Say Something are posted throughout the common areas.

Common areas: The living room and dining room are neat, clean and organized with sufficient seating for both residents and staff. Both rooms are properly furnished and in good repair. The facility maintains a comfortable temperature of seventy-five (75) degrees. No firearms observed or will be maintained on the premises. There is a working telephone on the premises.

Fireplace: LPA observed fireplace covered and inaccessible to residents. (Continue to LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Angelica Segovia
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SAM'S PRESTIGE CARE
FACILITY NUMBER: 197610809
VISIT DATE: 12/22/2025
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Resident/Staff files: The Resident and Staff files were observed to be kept in a locked cabinet located near the kitchen and inaccessible to residents. First-aid kit observed as well.

Kitchen: Sufficient supplies of nonperishable foods and perishable foods were observed. Sufficient supplies of dishes, cups, and silverware located within the kitchen cabinets and drawers. The knives/sharps were observed stored in a locked kitchen drawer and inaccessible to the residents. The kitchen appliances were observed to be working and in proper condition.

Emergency: The fire extinguisher was observed to be located near the kitchen.

Medications: The medications were observed to be kept in two (2) separate areas, kitchen cabinet and storage closet. The medication storages were observed to be equipped with a lock to ensure medications will not be accessible to residents.

Bedrooms: The bedrooms are properly furnished with bed, nightstand, applicable lightening, and seating. Window coverings are in good repair, not broken or damaged. LPA observed signal systems in each bedroom windows, working and in proper condition.

Bathroom: The bathrooms are in proper condition and observed to be equipped with sufficient personal hygiene for each resident. Towels and washcloths will not be shared. LPA observed appropriate grab rails and slip-resistant mats to be in proper condition.

Hallways: The hallways/passageways are lighted appropriately Extra linens/covers were observed to be kept in storage cabinet within the hallway’s passageway.

The Garage: The garage can be accessed from inside the facility. LPA observed the garage to be kept locked. LPA observed the garage to be used for extra storage with an additional freezer with extra food for residents.

Laundry: The laundry room was observed to be kept locked. LPA observed additional cleaning solutions/toxins properly stored within laundry room and inaccessible to residents. Dryer and washer observed to be in good repair.

Staff Room: LPA observed designated staff room to be locked and inaccessible to residents.

(Continue to LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Angelica Segovia
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2025
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SAM'S PRESTIGE CARE
FACILITY NUMBER: 197610809
VISIT DATE: 12/22/2025
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Water Temperature: The water temperature was measured in the bathrooms at 117 Fahrenheit, within regulations.

Smoke detectors: Dual interconnected smoke detectors and carbon monoxide observed to be working properly and were tested at 11:00 am.

Outside: The outside is clean, free of hazards, and properly furnished with sufficient seating. A shaded area for residents was observed as well.



Pool: There is no body of water.

Administration: The facility had submitted an Emergency and Disaster Plan For Residential Care Facilities For The Elderly and Infection plan.

Administrator: The Component III Orientation RCFE was shown/reviewed 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 conducted and copy of this report was provided to the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Angelica Segovia
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2025
LIC809 (FAS) - (06/04)
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