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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610286
Report Date: 07/12/2022
Date Signed: 07/13/2022 08:05:46 AM


Document Has Been Signed on 07/13/2022 08:05 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:PALM VISTA SENIOR LIVINGFACILITY NUMBER:
197610286
ADMINISTRATOR:MONTALVO, STUARTFACILITY TYPE:
740
ADDRESS:3850 WEST RANCHO VISTA BLVDTELEPHONE:
(530) 242-8300
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:115CENSUS: 12DATE:
07/12/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Stuart MontalvoTIME COMPLETED:
12:30 PM
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LPA Spaeth conducted an unannounced visit and was greeted by receptionist. LPA's temperature was recorded and LPA answered the COVID questions. LPA was then greeted by the Administrator and LPA stated the purpose of the visit was to conduct a post licensing visit. The Administrator confirmed there are twelve (12) residents at the facility.

The Administrator and LPA began the tour of the facility at 11:45 am. LPA was escorted throughout the first floor of the facility. Upon entering the dining hall, LPA observed dining staff wearing a mask and was delivering meals to the memory care section of the facility. LPA observed the key pad was used by staff to enter the memory section. At 11:55 am, LPA observed memory care residents were served lunch in the memory care dining room.

LPA observed the memory care section was neat and clean. Staff were assisting residents with lunch and staff were wearing surgical masks. LPA observed the public restrooms located on the first floor which contained wash your hands sign, hand soap, paper towels, grab bars, and a trash can.

LPA was then escorted to the second level of the facility. LPA observed a resident apartment which contained bed, linens, grab bars in the bathroom, night stand, night lamp, and comfortable seating. The locked storage room contained additional PPE supplies and other supplies needed for the facility.

LPA observed the medications were locked in a room on the second floor and also locked on the first floor. LPA observed the med carts were locked and also securely locked in the room

There are no deficiencies to report at this time. Exit interview conducted, appeal rights discussed, and a copy of the report was given to Administrator.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2022
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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