197610286-10-12-2023-31-AS-TAGD-CWYTZ9-20231026150956

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610286
Report Date: 10/12/2023
Date Signed: 10/12/2023 04:08:43 PM

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
11/29/2022 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20221129080606

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: 68	DATE:	10/12/2023
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Isabel Cortes		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility not meeting dietary needs of residents
Facility is not providing a variety of food and quantity necessary to meet the needs of the residents.
Facility is not providing various activities

INVESTIGATION FINDINGS:

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This is an amended copy of the report previously issued on 12/05/2022 and 01/04/2023. This report supersedes reports previously issued. The findings for this complaint have been updated.
Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced subsequent complaint investigation for the allegation(s) listed above and met with Isabel Cortes, Business Officer Manager.

The investigation consisted of the following: On 12/05/2022, LPA Spaeth conducted a 10-day visit, reviewed residents’ Dietary Communication Notifications and reviewed facility’s menu. LPA Spaeth received copies of the documents during the visit. On 01/04/2023, LPA interviewed 7 residents out of 41 and 5 out of 14 staff members.

Regarding the allegation: Facility not meeting dietary needs of residents. It’s being alleged that resident dietary needs are not met and that alternative meals are not provided. LPA interviewed (S3) who stated when a resident moves into the facility, Dietary Communication Notification sheets are completed for each

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: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

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-20221129080606

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: 10/12/2023

NARRATIVE

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resident. LPA reviewed the Dietary Communication Notifications for 3 residents with dietary needs out of 7. LPA observed the 3 identified residents need either a diabetic, low salt or low cholesterol diet. S3 stated they use a culinary computer application which provides a recipe in which S3 can alter to meet the required dietary needs of residents. LPA interviewed staff who confirmed residents with special dietary needs are served meals that meet their dietary requirements. Three residents confirmed receiving alternative meals which met their dietary needs.

Regarding the allegation: Facility is not providing a variety of food and quantity necessary to meet the needs of the residents. LPA reviewed the facility menus for the month of August 2022, 9/18/2022 through 12/02/2022. LPA observed a variety of meats such as fish, pork, beef, and chicken on the menu. LPA observed a variety of side dishes. LPA reviewed the vegetarian menu available to residents. LPA interviewed 7 out of 41 residents who stated there have been a few occasions when the facility ran out of the main course item but was offered another main course alternative. LPA interviewed staff who stated facility has provided a variety of food choices and the facility has provided the quantity needed to serve meals to the residents. On 10/06/2023, LPA conducted an additional interview and tour of the food supply with S3. LPA observed a two-day supply of perishable food and a seven-day supply of non-perishable food items.

Regarding the allegation Facility is not providing various activities. LPA Spaeth interviewed seven out of forty-one residents who stated facility offer a variety of activities which they enjoy. LPA interviewed S1 and S2 who stated facility provides a variety of activities.

Based on interviews conducted, and records reviewed, the allegations are unsubstantiated.

An exit interview was conducted, and a copy of the 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: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

LIC9099 (FAS) - (06/04)

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