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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610286
Report Date: 04/25/2023
Date Signed: 04/25/2023 02:55:29 PM


Document Has Been Signed on 04/25/2023 02:55 PM - 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: 46DATE:
04/25/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Stuart MontalvoTIME COMPLETED:
03:00 PM
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LPA Spaeth arrived to the facility and was greeted by Administrator. LPA stated the purpose of the visit was regarding a incident report received on 4/10/2023. Administrator confirmed there are forty six residents in the facility which include eleven residents in the memory care unit.

LPA and Administrator conducted a tour of the facility from 11:20 until 11:45 am. LPA did not observe any health of safety issues during the tour. LPA Spaeth reviewed resident's file (R1) at 12:00 pm until 12:30 pm and requested copies of the resident's file. LPA interviewed four staff members from 1:45 pm until 2:40 pm who worked on 4/10/2023 in the memory care unit.

It was reported to CCL that Resident 1 (R1) had been sitting outside within the facility memory care unit patio on 4/10/2023, The staff members observed R1 was experiencing hydration symptoms at about 1:30 pm. The medical technician called 911 and R1 was escorted to the hospital for heat exhaustion. R1 was returned to the facility the evening of 4/10/2023. The staff members confirmed were checking on R1 every thirty minutes when the resident was outside and also made sure R1 was drinking fluids.

There are no deficiencies to report. Exit interview conducted and a copy of the report was given to the Administrator.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2023
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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