197610286-6-14-2023-31-AS-MSPH-CSSL27-20230614082148

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610286
Report Date: 06/13/2023
Date Signed: 06/14/2023 08:21:55 AM

Document Has Been Signed on 06/14/2023 08:21 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

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: 56	DATE:	06/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Jeisy Pinoargote		TIME COMPLETED:	03:30 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 the Resident Care Director who stated the Administrator was attending an off-site training. LPA confirmed there are fifty-six residents in the facility. LPA was escorted by staff member (S1) for a tour of the facility at 10:00 am until 11:00 am. Dining Hall/Kitchen - LPA was greeted by the chef at 10:15 am and observed a seven-day supply of non-perishable items and a two-day supply of non-perishable fresh fruits, vegetables and meats. The dining area was prepared for the noon meal. The facility menu was also posted within the dining hall area. A snack bar is located outside the dining room and was stocked with coffee, tea, yogurt, fruit and cookies. Emergency Food/Water Supply – The chef escorted LPA to the second floor to a locked room which contained emergency food and water. Common Areas – LPA observed the common areas are spacious and contain comfortable seating. The exercise room contained work out equipment for the residents. Activity Room – The room contained tables and chairs along with games and other items. The activities calendar was also posted throughout the facility. LPA observed a library activity and residents were reading within a common area on the first floor. Residents’ Rooms – LPA observed eight apartments which contained bed, linens, night stand, lamp, chest of drawers and a closet. The cleaning staff were busy cleaning various apartments. Residents’ Bathrooms – Bathrooms contained walk in shower, sink, toilet, grab bars, and covered trash can. The water temperature was tested in Room 110 at 11:33 am and was 110.7 F.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/13/2023

NARRATIVE

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Memory Care Wing – LPA was escorted to the wing and observed S1 entered a code on a ten-key pad located at the entrance of the wing. LPA observed residents were participating in an activity. The kitchen area was neat and clean. Meals are transported from the kitchen located in the assisted living section to the memory care section. LPA observed dining room tables and chairs. The interior outside courtyard is furnished with comfortable seating along with a shaded area.

Memory Care Medication Room - LPA reviewed medication records with med tech staff member (S2) at 11:00 am until 11:20 am. LPA reviewed MARS documents along with medications for four memory care residents. The MARS report was up to date and accurate. .

Laundry Room – The door leading to the laundry room and was llocked. A staff member was washing residents’ clothing.

Assisted Living Medication Room - LPA reviewed medication records with med tech staff member (S3) at 11:20 am until 11:50 am. LPA reviewed MARS documents along with medications for four assisted living residents. The MARS report was up to date and accurate.

Assisted Living Outdoor Courtyard- The courtyard contained comfortable seating and a shaded area.

Emergency Fire Drill – LPA observed fire drill took place on 3/08/2023.

Residents’ Records -LPA reviewed residents' records at 12:00 pm until 1:00 pm. The records were accurate.

Staff Records - LPA reviewed five staff records at 1:15 pm until 2:15 pm,. The records were accurate.

There are no deficiencies to report at this time. Exit interview conducted, and a copy of the report was given to the staff member.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023

LIC809 (FAS) - (06/04)

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