197606568-4-3-2025-31-AS-MSPH-DFDV3G-20250403160440

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606568
Report Date: 04/03/2025
Date Signed: 04/03/2025 04:05:21 PM

Document Has Been Signed on 04/03/2025 04:05 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:	PALMDALE CARE FACILITY		FACILITY NUMBER:	197606568
ADMINISTRATOR/ DIRECTOR:	VALEREE ZEPEDA		FACILITY TYPE:	735
ADDRESS:	2810 E. AVENUE R-15		TELEPHONE:	(661) 264-0450
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93550
CAPACITY: 4		CENSUS: 4	DATE:	04/03/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:45 AM
MET WITH:	Valeree Zepeda		TIME VISIT/ INSPECTION COMPLETED:	02:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by the Administrator, Valeree Zepeda. The Administrator confirmed there are four residents. The facility is licensed for four ambulatory and two non-ambulatory clients..

LPA Spaeth and the Administrator toured the facility at 11:50 am until 12:25 pm.

Living Room/Dining Room - When entering the facility, the living room is furnished with comfortable seating and a television. The dining room contains a dining room table and chairs. The medications are locked in a cabinet.

Kitchen - The facility contained a two day supply of perishable food and a seven day supply of non-perishable foods. The fire extinguisher is located in the kitchen and is operable.

Backyard- LPA observed comfortable furniture located in the backyard. The gate leading from the backyard to the front yard was not locked.

Garage//Washer & Dryer – The garage was locked and contained PPE, an additional refrigerator and the, washer/dryer and laundry soap.

Continued 9099-C

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Melissa Spaeth
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025

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

FACILITY NAME: PALMDALE CARE FACILITY	FACILITY NUMBER: 197606568
	VISIT DATE: 04/03/2025

NARRATIVE

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Hallway Closet - LPA observed the closet was locked and contained cleaning solutions.

Bathroom - LPA observed the bathroom contained hand soap and paper towels. The bathroom was nice and clean.

Resident Rooms: The resident rooms were furnished with a bed, linens, night stand, lamp and chair.

Staff Room - LPA observed the staff room was locked. The knives are locked in the staff room.

Water Temperature: LPA tested the water temperature at 12:10 pm and the temperature was 121.6 degrees F.

Smoke/Carbon Monoxide Detectors: The smoke and carbon monoxide detectors were tested at 12:20 pm and were operable.

LPA Spaeth reviewed resident record at 12:30 pm until 12:55 pm. LPA also reviewed the staff records at 12:55 pm until 1:20 pm. LPA Spaeth reviewed the resident's medication at 1:20 pm until 1:30 pm.

There are no deficiencies at this time. Exit interview conducted and a copy of the report was given.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Melissa Spaeth
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/03/2025 04:05 PM - It Cannot Be Edited

Created By: Melissa Spaeth On 04/03/2025 at 01:23 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: PALMDALE CARE FACILITY	FACILITY NUMBER: 197606568
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observations, the licensee did not comply with the section cited above. The water temperature was 122.5 degree F which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/03/2025
	Plan of Correction
1 2 3 4	During LPA's visit, the water heater was adjusted. At 1:05 pm, LPA tested the water temperature which was 111.0 degrees F.

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.

	Troy Agard
NAME OF LICENSING PROGRAM MANAGER:

	Melissa Spaeth
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025

LIC809 (FAS) - (06/04)

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