197610286-7-18-2022-31-AS-CHAS-CHPNV7-20220827104728

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610286
Report Date: 07/15/2022
Date Signed: 07/18/2022 10:54:03 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/08/2022 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20220708124028

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: 18	DATE:	07/15/2022
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Stuart Montalvo		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff mismanaged resident's medication
Staff inaccurately record resident medications on the facility MAR
Staff yelled at resident in care

INVESTIGATION FINDINGS:

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LPA Spaeth conducted an unannounced visit regarding the above-referenced allegations. LPA met with Administrator and LPA stated the purpose of the visit was to investigate thre three allegations mentioned above. LPA conducted a tour of the facility from 10:10 am until 10:30 am. LPA did not observe any health and safety issues. LPA Spaeth interviewed the Administrator from 9:55 am until 10:10 am. LPA interviewed residents from 10:30 am until 12:15 pm.

Regarding allegations, staff mismanaged resident's medication, LPA interviewed three residents who receive assistance with medications. All three residents stated receive medication on time and there is never a shortage of medication. Staff members were interviewed and confirmed there has never been a shortage of medication and the medical technicians provide the medication in a timely manner. Also, LPA and the Resident Care Director conducted a medication check evaluation at 1:45 pm and confirmed residents' medication have been properly dispersed to the residents.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022

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-20220708124028

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/15/2022

NARRATIVE

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LPA requested medication documentation for three residents at 12:00 p.m. LPA reviewed MAR documentation and determined that medical tech staff had properly recorded all resident medications on the MAR documentation. LPA also interviewed the Resident Care Director who confirmed the medical techs. follow the Title 22 Regulations when residents refuse medication and confirmed that medication records are not falsely recorded. LPA interviewed staff members and medical tech staff who stated records are correct. Therefore the allegation, staff inaccurately record resident medications on the facility MAR is unsubstantiated.

In regard to the allegation, staff yelled at resident in care. LPA interviewed residents who stated staff members have not yelled at residents. Residents also confirmed had not witnessed a staff member yell at a resident. The residents confirmed staff treat residents with respect. Therefore this allocation is unsubstantiated.

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

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022

LIC9099 (FAS) - (06/04)

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