197608195-8-12-2026-31-AS-ERIS-DWVVH6-20260812162638

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608195
Report Date: 08/12/2026
Date Signed: 08/12/2026 04:26:49 PM

Document Has Been Signed on 08/12/2026 04:26 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, LLC		FACILITY NUMBER:	197608195
ADMINISTRATOR/ DIRECTOR:	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: 3	DATE:	08/12/2026
TYPE OF VISIT:	POC	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:38 PM
MET WITH:	Staff - Ivy Ceralde		TIME VISIT/ INSPECTION COMPLETED:	04:41 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) Evelin Rios arrived to this facility to conduct and unannounced POC visit for citations issued on 08/02/2026. LPA rang the door bell and was greeted by a staff member. Staff contacted the administrator Jojomaureli B. Salamero by telephone and LPA informed the administrator the purpose of the visit. Original Citations and POC's with results of the POC visit are as follows: 87303(e)(2) Maintenance and Operation: BATHROOM #1 127.3/ BATHROOM #2 125.6. POC: Administrator will lower water temperature and send LPA picture. Administrator will create a water log for one week and send to LPA by POC due date 08/03/26. Staff provided LPA a copy of the water log for testing conducted by staff around 8 AM. Log has temperatures within range. At around 3:30 PM LPA tested the water in Bathroom #1 and Bathroom #2, temperatures read 119 degrees Fahrenheit. POC cleared today. 87309(a) Storage Space and Access: Laundry detergent, bleach, and other cleaning supplies were left on top of the washing machine unlocked. POC: Administrator will provide training with staff on section 87309(a) and send log to LPA by POC due date 08/03/2026. LPA reviewed a copy of training. POC cleared today. 87465(h)(2) Incidental Medical and Dental Care Services: Comfort care medication was observed unlocked in refrigerator. POC: Administrator will purchase lock box and send picture to LPA by POC due date 08/03/26. LPA observed two lock boxes in the refrigerator. POC cleared today. (Continue to LIC809-C)

Mary G Flores
Evelin Rios
	DATE: 08/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2026

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: PALMDALE SENIOR VILLA, LLC	FACILITY NUMBER: 197608195
	VISIT DATE: 08/12/2026

NARRATIVE

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87470(c) Infection Control Requirements: Infection control plan was not available at time of visit. POC: Administrator will email infection control plan to LPA by POC due date 08/09/26. LPA reviewed a copy of the facility's Infection Control Plan. POC cleared today.

H&S Code 1569.605 Other Provisions: Liability insurance was not provided at time of visit. POC: Administrator will email a valid insurance to LPA by POC due date 08/09/26. LPA reviewed a copy of the Liability Insurance. POC cleared today.

87303(a) Maintenance and Operation: LPA observed four (4) ripped chairs in kitchen and one broken towel bar in bathroom. POC: Administrator will send LPA pictures of corrected items by POC due date 08/09/26. LPA observed a new towel rack and the four chairs had new upholstery. POC cleared today.

87412(a) Personnel Records: Administrator and S2 did not have file at time of visit. POC: Administrator will send completed files to LPA by POC due date 08/09/26. LPA reviewed administrator's and staff Anthony Castro's file. POC cleared today.

H&S 1569.625(b)(2) Other Provisions: S2 did not have any training. POC: Administrator will send S2's annual training to LPA by POC due date 08/09/26. LPA reviewed staff Anthony Castro's training. POC cleared today.

87219(h)(2) Planned Activities: LPA did not observe a shaded outdoor area for residents to sit outside. POC: Administrator will send LPA Pictures of shaded seating area by POC due date 08/09/26. LPA observed an outdoor umbrella. POC cleared today.

(Continue to LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2026

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: PALMDALE SENIOR VILLA, LLC	FACILITY NUMBER: 197608195
	VISIT DATE: 08/12/2026

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87465(a)(6) Incidental Medical and Dental Care Services: Residents did not have a current medication list from doctor with all medications and PRN's. POC: Administrator will send a current list with all active medication including PRN's to LPA by POC due date 08/09/26. LPA reviewed resident's medication list. POC cleared today.

87463(h) Reappraisals: R3 did not have current medical exam LIC 602. POC: Updated 602 will be sent to LPA by POC due date 08/09/26. LPA reviewed an appointment confirmation provided between the administrator and R3's responsible person indicating an appointment to update LIC602 has be scheduled for August 14, 2026. Administrator will send updated LIC602 to the Department following the appointment. POC extension granted. POC due date is now 08/18/26.

H&S 1569.695(a) Other Provisions: Emergency disaster plan was not present at time of visit. POC: Administrator will send 610E to LPA by POC due date 08/09/26. LPA reviewed LIC610E. POC cleared today.

H&S 1569.695(c) Other Provisions: Facility did not have drill at time of visit. POC: Administrator will send last drill conducted to LPA by POC due date 08/09/26. LPA reviewed Fire drills conducted. POC cleared today.

Administrator emailed LPA copies of documents reviewed during todays visit. LPA will update facility's file in the Regional office. No immediate health and safety issues observed. Exit interview conducted. Copy of report provided to staff member.

NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2026

LIC809 (FAS) - (06/04)

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