197608195-6-12-2023-31-AS-JGTN-CSPVH4-20230611162631

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608195
Report Date: 06/11/2023
Date Signed: 06/12/2023 07:47:42 AM

Document Has Been Signed on 06/12/2023 07:47 AM - 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 SENIOR VILLA, LLC		FACILITY NUMBER:	197608195
ADMINISTRATOR:	JOJOMAURELI B. SALAMERO		FACILITY TYPE:	740
ADDRESS:	38719 37TH STREET EAST		TELEPHONE:	(661) 526-4394
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93550
CAPACITY:	6	CENSUS: 6	DATE:	06/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:49 PM
MET WITH:	Jojomaureli Salamero - Administrator		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Gary Tan conducted a One Year Required visit at this facility today and was greeted by staff Nilo and Joann Singson. Administrator Jojomaureli Salamero was called and arrived shortly. LPA informed the administrator the purpose of the visit. LPA observed that all the five (5) residents were at their respective bedrooms resting/sleeping. LPA was informed that that one (1) resident was in the hospital. At 1:03 PM, A tour of the physical plant was conducted with Ms. Salamero. The facility has five (5) bedrooms and two (2) bathrooms currently occupying six (6) residents. One (1) bedroom is designated for staff use. The facility fire cleared for five (5) non-ambulatory residents, one of which maybe bedridden. Infection control: The facility has submitted and approved Mitigation Plan and Infection Control plan on file. The main door is the only entrance being utilized at the facility. There is a sign on the door that everyone entering at the facility must wear mask. Screening area is located in immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. Hand washing sign are posted on the bathroom. Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, the following was noted: Living and dining room furniture were also checked. The living room is neat and clean. The facility maintains a comfortable temperature at 75°F. The smoke detectors and alarms are interconnected and hardwired and observed to be fully operational. There is a carbon monoxide installed and observed to be operational. The door alarms were also and observed to be operational. The fire extinguisher is located at the dining room and observed to be full and current. (continued to LIC 809-C)

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2023

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

FACILITY NAME: PALMDALE SENIOR VILLA, LLC	FACILITY NUMBER: 197608195
	VISIT DATE: 06/11/2023

NARRATIVE

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(continued from LIC 809)

The backyard of the facility has outdoor furniture. There is no body of water at the facility. The garage was observed to be locked and inaccessible to residents and also being used as storage for frozen food, other supplies and laundry detergent and other toxins. Laundry area is located on the hallway going to the garage.
Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Cleaning supplies, pesticides, detergents and/or toxins are stored in the cabinet below the kitchen sink and were locked and inaccessible to residents. Knives and sharps are also locked in a kitchen drawer.
The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are appropriately lit. Clients have sufficient amounts of personal hygiene product which is provided by the licensee.
Staff Rooms: Staff room was locked. No medication was observed in the staff room.
The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. The hot water temperature measured at a range of 113.7°F to 114.3°F . Towels and washcloths are not shared. There is enough clean linen available in stock at the cabinet.
Medications: LPA observed medication in the kitchen area cabinet to be locked and inaccessible to residents. Medications are listed on the centrally stored medication and destruction record. The first aid kit was complete and stored in the medication cabinet.
Client records: Client records are reviewed. Residents #1 and #2 had no physician's report on file.
Staff records: LPA conducted a complete file review of staff records. Staff #1 (S1) & Staff #2 (S2) had no health screening on file.
Disaster drill was last conducted on 03/08/23. Required posting are observed to be complete and current and displayed properly at the facility.

Citation issued. Appeal rights discussed and given. Exit interview conducted and copy of this report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/12/2023 07:47 AM - It Cannot Be Edited

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 SENIOR VILLA, LLC	FACILITY NUMBER: 197608195
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87456(a)(3)

Evaluation of Suitability for Admission

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's record review, the licensee did not comply with the section cited above in 2 out of 6 residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/21/2023
	Plan of Correction
1 2 3 4	The administrator agreed to submit a copy of the R1 & R2's LIC 602 on or before the POC date.

Type B

Section Cited

CCR

87411(F)

All personnel including the administrator, shall be in good health and physically and mentally capable of performing assigned tasks. Good physical shall be verified by a health screening, including chest x ray or an intra dermal test by a physician not more than six (6) months to or seven (7) days after employment or licensure... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's record review, the licensee did not comply with the section cited above in 2 out 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/21/2023
	Plan of Correction
1 2 3 4	The administrator agreed to obtain health screening for S1 & S2 on or before the POC date and submit a copy to CCL

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	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2023

LIC809 (FAS) - (06/04)

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