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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610286
Report Date: 04/19/2024
Date Signed: 04/23/2024 10:56:05 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/02/2023 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20230502121813
FACILITY NAME:PALM VISTA SENIOR LIVINGFACILITY NUMBER:
197610286
ADMINISTRATOR:MONTALVO, STUARTFACILITY TYPE:
740
ADDRESS:3850 WEST RANCHO VISTA BLVDTELEPHONE:
(661) 202-3999
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:115CENSUS: DATE:
04/19/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jeisy PinoargoteTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Facility staff did not accurately assess resident's needs.
Facility staff did not communicate with resident's family.
Facility staff did not ensure that resident's room was free of clutter in the walkways.
Resident sustained pressure injuries while in care.
Facility staff did not provide needed care and assistance to resident.
Facility staff did not ensure that resident had hot water for showers
Facility staff did not ensure that resident received medical attention while in care.
Facility staff did not ensure that resident was being fed while in care.
INVESTIGATION FINDINGS:
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On 4/18/2024 Licensing Program Analyst (LPA), Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth was met by Jeisy Pinoargote, Resident Care Director. LPA explained the purpose of this visit was to conduct interviews and present findings. LPA conducted a physical tour at 9:45am to 10:10 am.

The investigation consisted of the following: on 05/04/2023, LPA Spaeth initiated a complaint investigation. LPA reviewed resident files and interviewed seven residents. LPA received copies of the documentation. On 4/18/2024, LPA Spaeth reviewed resident documents at 10:30 am until 11:30 am. LPA interviewed residents and received copies of resident’s documents.

The investigation revealed the following regarding the allegation: Facility staff did not accurately assess resident’s needs. It’s being alleged that facility staff did not accurately assess the care a resident (R1)
cont'd 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 31-AS-20230502121813
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: PALM VISTA SENIOR LIVING
FACILITY NUMBER: 197610286
VISIT DATE: 04/19/2024
NARRATIVE
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needed. LPA interviewed four (4) out of twenty-six (26) staff members who stated residents have stated the facility staff accurately assessed resident’s needs. LPA interviewed six (6) out of sixty-three residents who stated staff accurately assessed resident’s needs. Therefore the allegation is unsubstantiated.

Regarding the allegation: Facility staff did not communicate with resident’s family members. It’s being alleged that the staff did not communicate to the residents and to their family members. LPA interviewed six (6) out of sixty-three residents who stated staff properly communicate with the resident and family members. Four (4) out of the twenty-six (26) staff members interviewed unanimously stated they communicate to the residents and their families. Therefore the allegation is unsubstantiated.

Regarding the allegation: Facility staff did not provide needed care and assistance to the resident. It’s being alleged that the staff do not meet the resident’s needs. LPA interviewed six (6) out of sixty-three residents who stated staff provides the care they need. Four (4) out of the twenty-six (26) staff members interviewed unanimously stated they provide the care needed for each resident. It was also alleged that R1 was not taking medication and R1’s bed was soiled. Two med tech staff members confirmed R1 took medication as prescribed. R2 confirmed R1 and R2 lived in the same room and also confirmed that R1 had taken medication. R2 also stated staff changed R1’s bed when it was soiled. Six (6) out of sixty-three (63) residents who stated staff never miss giving their medication and if their bed is soiled, staff immediately change the linens. R1 did not want to be interviewed. Therefore the allegation is unsubstantiated.

Regarding the allegation: Facility staff did not ensure that resident had hot water for showers.- It’s being alleged that there was no hot water at the facility and R1 did not shower for four weeks due to the lack of hot water. LPA interviewed six (6) out of sixty-three residents who stated there has not been any issues with the hot water. All six (6) residents confirmed they have not missed showering for four weeks. R1 did not want to be interviewed. Four (4) out of the twenty-six (26) staff members interviewed unanimously stated the facility has not had any hot water issues. The Administrator stated hot water was not available for one day when the facility opened but that the issue was repaired. Therefore the allegation is unsubstantiated.

Regarding the allegation, Facility staff did not ensure that resident's room was free of clutter in the walkways. It was alleged that R1’s apartment was cluttered. During LPA’s visit on 5/04/2023, LPA observed R1’s apartment was not cluttered. Six (6) out of the sixty-three (63) residents stated their rooms have never been cluttered. Therefore the allegation is unsubstantiated.

contd 9099-C

SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20230502121813
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: PALM VISTA SENIOR LIVING
FACILITY NUMBER: 197610286
VISIT DATE: 04/19/2024
NARRATIVE
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Regarding the allegation, Resident sustained pressure injuries while in care…its alleged that a resident sustained pressure injuries while in care. LPA observed R1's documentation that R1 received wound care. Four (4) out of the twenty-six (26) staff members confirmed the residents received the care they need and residents have not developed wounds due to staff neglect. The Resident Care Director confirmed R1 received wound care but there are no residents at this time receiving wound care. Six (6) out of the sixty three (63) residents confirmed staff meet their needs and do not have any wounds. R1 refused to be interviewed. Therefore the allegation is unsubstantiated.

Regarding the allegation, Facility staff did not ensure that resident was being fed while in care. It is alleged a resident (R1) did not receive meals because R1 would not go to the dining hall because R1 would be charged for staff assisting the resident to the dining hall. R2 confirmed since living in the room with R1, R2 went to the dining hall to pick up R1’s meals. Four (4) out of the twenty-six (26) staff members confirmed R2 picked R1’s meals every day. Six (6) out of the sixty-three (63) residents confirmed they receive three meals per day. Therefore the allegation is unsubstantiated.

Regarding the allegation…Facility staff did not ensure that resident received medical attention while in care. It is alleged that staff did not provide transportation to R1 for doctor’s appointments. R2 confirmed they scheduled the trips to the doctor for R1. The Activities Director confirmed they drive residents to their doctor’s appointments. The Activities Director confirmed R2 made the reservations for R1 and R2 to be transported to doctor’s appointments. Therefore, the allegation is unsubstantiated.

Exit interview conducted and a copy of the signed report was given.

SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3