197610286-4-19-2024-31-AS-RORN-D5BP5Z-20240516110133

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610286
Report Date: 04/18/2024
Date Signed: 04/19/2024 07:49:14 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
06/30/2023 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20230630143812

FACILITY NAME:	PALM VISTA SENIOR LIVING		FACILITY NUMBER:	197610286
ADMINISTRATOR:	MONTALVO, STUART		FACILITY TYPE:	740
ADDRESS:	3850 WEST RANCHO VISTA BLVD		TELEPHONE:	(661) 202-3999
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY:	115	CENSUS: 63	DATE:	04/18/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Stuart Montalvo		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff inappropriately forced resident into memory care

INVESTIGATION FINDINGS:

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On 3/25/2024 Licensing Program Analyst (LPA), Melissa Spaeth and Licensing Program Manager (LPM), Troy Agard conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth and LPM Agard were met by Stuart Montalvo, Administrator. LPA explained the purpose of this visit was to gather additional information, conduct interviews and deliver the findings for this complaint. LPA conducted a physical tour at 9:45am to 10:10am.

The investigation consisted of the following: on 07/06/2023, LPA Spaeth initiated a complaint investigation. LPA toured the facility and reviewed files. On 04/18/2024, LPA Spaeth and LPM Agard conducted interviews and reviewed additional records.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230630143812

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: 04/18/2024

NARRATIVE

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The investigation revealed the following… regarding the allegation: Staff inappropriately forced resident into memory care. It's being alleged that a resident is being placed in memory care that did not previously have a diagnosis of dementia for the sake of financial gains. During an interview with S1, they state R1 began to show signs of having moments of forgetfulness and confusion, episodes of incontinence and sundowning. S2 states R1’s placement is necessary due to their current needs. R1 was assessed by a physician in May of 2023 who noted a diagnosis of dementia. LPM Agard attempted an interview with R1 and observed signs of confusion.

During a record review from 11:30am to 12:30pm, LPA and LPM reviewed R1’s physician report dated for 05/12/2023 which indicates R1 has a diagnosis of dementia. It was observed R1 had several needs and services assessments completed. R1 was initially assessed on 06/20/2023 and it shows R1 was independent in all activities of daily living. Resident was again assessed on 01/15/2024 and it indicates that R1 started to require support with some areas of their activities of daily living. LPA and LPM reviewed R1’s resident assessment conducted on 05/12/2023, 06/20/2023, 12/14/2023 and 01/25/2024 which indicated residents’ progression in their stages of dementia and their need for additional supports and services. All assessments and needs and services plan were observed to have verbal or written consent from R1’s power of attorney.

Based on interviews, observation and a review of records the above allegation is unsubstantiated. Exit interview conducted and a copy of the signed report was given.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

LIC9099 (FAS) - (06/04)

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