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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608195
Report Date: 08/02/2026
Date Signed: 08/02/2026 01:28:46 PM

Document Has Been Signed on 08/02/2026 01:28 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:PALMDALE SENIOR VILLA, LLCFACILITY NUMBER:
197608195
ADMINISTRATOR/
DIRECTOR:		JOJOMAURELI B. SALAMEROFACILITY TYPE:
740
ADDRESS:38719 37TH STREET EASTTELEPHONE:
(661) 526-4394
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 6CENSUS: 3DATE:
08/02/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:11 AM
MET WITH:Ivy CeraideTIME VISIT/
INSPECTION COMPLETED:
01:43 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met with caregiver Ivy Ceraide and explained the purpose of today’s visit. Administrator Jojomaureli Salamero was notified by telephone.

Facility is licensed to serve Residents ages 60 and over. Approved fire clearance for 5 non-ambulatory, two (2) residents in room #1, two (2) residents in room #4, and one (1) resident in room #2. One (1) bedridden in room #3. Staff room #5 87705 compliant. Hospice waiver for 2 residents. The facility is single story house located in a residential neighborhood in the city of Palmdale. LPA toured the facilities physical plant, indoor and outdoor. The facility has a formal living room/dining room, four (4) resident bedrooms, one (1) staff room, two (2) bathrooms (one of which is in bedroom #1), kitchen with dining area and second living room, laundry area, and attached garage used for storage.

LPA toured the facility and observed the following: All resident bedrooms have the required furniture and bedding. There is extra clean linen and towels in hallway cabinets. Smoke detectors/carbon monoxide detectors were observed throughout facility. The facility has one (1) fire extinguisher which is kept in kitchen. LPA observed four kitchen chairs to all be torn. Cleaning supplies and toxic substances were observed to be accessible to residents in care in laundry area in top of washing machine. Sharps are locked in drawer in kitchen. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 40 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. LPA observed a box of unlocked comfort care medication in refrigerator. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured not between the required range of 105-120 degrees F. Bathroom #1 127.3 and bathroom #2 125.6. There is a broken bar in bathroom #2. The facility does not have a swimming pool or large body of water. LPA did not observe a shaded seating area for the residents. Passageways and exits are free of obstruction.

David Sicairos
Christian Gutierrez
DATE: 08/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 11
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: PALMDALE SENIOR VILLA, LLC
FACILITY NUMBER: 197608195
VISIT DATE: 08/02/2026
NARRATIVE
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Two (2) out of four (4) staff files were reviewed and included Criminal clearance record, required training TB. Administrator and S3 files was not available at time of visit. Three (3) resident files were reviewed and R1 was missing current physician report LIC 602. Infectious control plan, emergency disaster plan, and drill were not reviewed and will be emailed to LPA. Administrator will email current liability insurance. Residents did not have a current list of medications from physician. Medications are centrally stored in living room in a licked cabinet.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during today’s visit will be documented on LIC809-D. Exit interview was held and a copy of the report with appeal rights was given.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2026
LIC809 (FAS) - (06/04)
Page: 11 of 11
Document Has Been Signed on 08/02/2026 01:28 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 08/02/2026 at 12:15 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 SENIOR VILLA, LLC
FACILITY NUMBER: 197608195

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above comfort care medication was observed unlocked in refrigerator which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/03/2026
Plan of Correction
1
2
3
4
Administrator will purchase lock box and send picture to LPA by POC due date.
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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2026


LIC809 (FAS) - (06/04)
Page: 4 of 11
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)
Page: 2 of 11
Document Has Been Signed on 08/02/2026 01:28 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 08/02/2026 at 12:15 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 SENIOR VILLA, LLC
FACILITY NUMBER: 197608195

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in two (2) out of two (2) bathrooms had a reading higher than 120 degrees which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/03/2026
Plan of Correction
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BATHROOM #1 127.3/BATHROOM #2 125.6.
Administrator will lower water temperature and send LPA picture.
Administrator wil create a water log for one week and send to LPA.
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above laundry detergent,bleach, and other cleaning supplies were left on top of the washing machine unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/03/2026
Plan of Correction
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2
3
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Staff removed cleaners at time of visit.
Administrator will provide training with staff on section 87309(a) and send log to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2026


LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 08/02/2026 01:28 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 08/02/2026 at 12:15 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 SENIOR VILLA, LLC
FACILITY NUMBER: 197608195

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

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 in Administrator and S2 did not have file at time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2026
Plan of Correction
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2
3
4
Administrator will send completed files to LPA by POC due date.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

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 S2 did not have any training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2026
Plan of Correction
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2
3
4
Administrator will send S2's annual training to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2026


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 08/02/2026 01:28 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 08/02/2026 at 12:15 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 SENIOR VILLA, LLC
FACILITY NUMBER: 197608195

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.

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 infection control plan was not avalible at time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2026
Plan of Correction
1
2
3
4
Administrator will email infection control plan to LPA by POC due date.
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

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 LPA was not provided INS at time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2026
Plan of Correction
1
2
3
4
Administrator will email a valid insurance to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2026


LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 08/02/2026 01:28 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 08/02/2026 at 12:15 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 SENIOR VILLA, LLC
FACILITY NUMBER: 197608195

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above LPA observed four (4) ripped chairs in kitchen and one broken towel bar in bathroom which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2026
Plan of Correction
1
2
3
4
Administrator will send LPA pictures of corrected items by POC due date.
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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2026


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 08/02/2026 01:28 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 08/02/2026 at 12:15 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 SENIOR VILLA, LLC
FACILITY NUMBER: 197608195

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(h)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

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 R3 did not have current medical exam LIC 602 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2026
Plan of Correction
1
2
3
4
Updated 602 will be sent to LPA by POC due date.
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

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 emergency disater plan was not present at time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2026
Plan of Correction
1
2
3
4
Administrator will send 610 E to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2026


LIC809 (FAS) - (06/04)
Page: 9 of 11
Document Has Been Signed on 08/02/2026 01:28 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 08/02/2026 at 12:15 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 SENIOR VILLA, LLC
FACILITY NUMBER: 197608195

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

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 facility did not have drill at time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2026
Plan of Correction
1
2
3
4
Administrator will send last drill conducted to LPA by POC due date.
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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2026


LIC809 (FAS) - (06/04)
Page: 10 of 11
Document Has Been Signed on 08/02/2026 01:28 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 08/02/2026 at 12:15 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 SENIOR VILLA, LLC
FACILITY NUMBER: 197608195

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87219(h)(2)
Planned Activities
(h) The licensee shall provide sufficient space to accommodate both indoor and outdoor activities. Activities shall be encouraged by provision of: (2) Outdoor activity areas that are easily accessible to residents, protected from traffic, and have adequate shady areas.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above LPA did not observe a shaded outdoor area for residents to sit outside which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2026
Plan of Correction
1
2
3
4
Administrator will send LPA Pictures of shaded seating area by POC due date.
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review, the licensee did not comply with the section cited above residents did not have a current medication list from doctor with all medications and PRN's which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2026
Plan of Correction
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Administrator will send a current list with alll active medication including PRN's to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2026


LIC809 (FAS) - (06/04)
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