<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610286
Report Date: 11/23/2022
Date Signed: 11/28/2022 07:53:34 AM


Document Has Been Signed on 11/28/2022 07:53 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:
(661) 202-3999
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:115CENSUS: 40DATE:
11/23/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Stuart MontalvoTIME COMPLETED:
01:30 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 conducted an unannounced visit and was greeted by Administrator. LPA stated the purpose of the visit was regarding an incident report received by CCL. Administrator confirmed there are forty residents at the facility. Upon arrival, LPA's temperature was recorded and LPA answered the COVID questions. LPA observed hand sanitizer and masks available at the sign in station.

LPA and Administrator toured the facility from 9:45 am until 10:15 am. LPA observed all staff were wearing masks. LPA observed there is a seven-day supply of perishable canned goods and a two-day supply of fresh fruits and vegetables. The public bathrooms were supplied with wash your hands sign, paper towels, hand soap, and a trash can.

LPA observed the memory care section of the facility. There were three residents watching the morning news on the television and a resident eating breakfast. LPA observed the facility was neat and clean.

LPA reviewed resident files at 10:25 am until 11:00 am. LPA discussed the incident reports with Administrator and Resident Care Director from 1:00 pm until 1:18 pm. Based upon LPAs discussion with Administrator and Resident Care Director, there are no issues.

There were no deficiencies to report at this time. 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: 11/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1