197610286-6-1-2022-31-AS-MSPH-CEYRD9-20220601125531

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610286
Report Date: 06/01/2022
Date Signed: 06/01/2022 12:56:18 PM

Document Has Been Signed on 06/01/2022 12:56 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	PALM VISTA SENIOR LIVING		FACILITY NUMBER:	197610286
ADMINISTRATOR:	MONTALVO, STUART		FACILITY TYPE:	740
ADDRESS:	3850 WEST RANCHO VISTA BLVD		TELEPHONE:	(530) 242-8300
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY:	115	CENSUS:	DATE:	06/01/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Stuart Montalvo		TIME COMPLETED:	12:00 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	LPA Spaeth arrived at the facility at 8:45 am and was greeted by the receptionist. LPA's temperature was recorded and LPA answered the COVID screening questions at the front desk. LPA was greeted by the Executive Director, Stuart Montalve. The Executive Director confirmed the facility is a two-story property with seventy (70) apartments in the assisted living section and twenty-five (25) apartments in the memory care section. LPA and the Executive Director began the tour at 9:00 am. LPA observed the entrance to the facility contains a large public seating area which includes a bar and bistro area. The activities sheet was posted on the first floor and also in other locations throughout the facility. The dining hall seats 97 residents and LPA Spaeth observed various sized tables with adequate seating for dining. The kitchen contained a food prep area with the required equipment for cooking and cleaning. The pantry was stocked with the required amount of dry goods and canned goods. The walk-in refrigerator contained fresh fruits and vegetables which were properly stored. Also, the walk in freezer contained frozen meats and vegetables. LPA observed the sink for washing hands contained wash your hands sign, paper towels, and hand soap. There are three public bathrooms located on the first floor which are supplied with wash your hands sign, hand soap, paper towels, and a trash can. The staff break room was spacious and contained comfortable seating for staff. A med tech room is set up on the first floor for the assisted living residents. The room was locked and LPA observed the med cart was available for use. A library room is also available for residents. LPA observed Room 112 which is a one bedroom location and observed Room 114 which is a studio location. Both locations contained comfortable seating and a bed and linens. The shower is a walk in shower and a non-skid mat will be provided to the residents. At 9:01 am, LPA observed the water temperature in a resident's bathroom was 118 degrees F.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PALM VISTA SENIOR LIVING	FACILITY NUMBER: 197610286
	VISIT DATE: 06/01/2022

NARRATIVE

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LPA was then escorted to the memory care section and was informed all visitors will be escorted by staff when visiting memory care residents. The security pad was located at the memory care doorway. LPA observed the virtual reality room, activity room, med tech room, and dining area within the memory section of the facility. When viewing the med tech room, LPA observed a security code was needed to enter the med tech room and to exit the room. The Executive Director stated the resident bathroom cabinets contain a magnet as a safety measure. LPA then exited a door to the memory care courtyard which is an interior area for memory care residents. This area contained a shaded area with comfortable seating. The emergency food and PPE supplies are stored on the second floor in a locked room.

Within the stairwell area, LPA observed the required evacuation chairs. Fire extinguishers were located throughout the building. LPA also observed the smoke and carbon monoxide detectors which are centrally connected and managed by an outside company. LPA also observed the mechanical room which contained an emergency supply of water. LPA observed various postings of the Let Us Know signs.

LPA conducted the Comp III presentation to the Executive Director at 11:25 am. Upon LPA's conclusion of the tour, LPA did not observe any issues at this time.

Exit interview was conducted, appeal rights discussed, and a copy of the report was given to the Executive Director.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022

LIC809 (FAS) - (06/04)

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