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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610286
Report Date: 01/04/2023
Date Signed: 01/04/2023 08:13:12 PM

Substantiated


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
11/29/2022 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20221129080606
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: 41DATE:
01/04/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Stuart MontalvoTIME COMPLETED:
07:00 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.

INVESTIGATION FINDINGS:
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LPA conducted an unannounced visit and was greeted by Administrator. LPA observed receptionist was wearing a mask and all staff throughout the facility were wearing masks. LPA stated the purpose of the visit was to investigate the allegations: 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; and Facility is not providing various activities. LPA toured the facility from 10:00 am until 10:20 am. LPA did not observe any health or safety issues. LPA interviewed staff and residents at 12:30 pm until 4:00 pm and reviewed residents’ records at 4:00 pm until 5:00 pm.

Facility Not Meeting Dietary Needs of Residents - LPA interviewed four residents who have special dietary needs. All four residents stated within the last two months residents were served several meals that did not meet the dietary requirements. Therefore, the allegation is substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
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
11/29/2022 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20221129080606

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: 41DATE:
01/04/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Stuart MontalvoTIME COMPLETED:
07:00 PM
ALLEGATION(S):
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9
Facility is not providing various activities
INVESTIGATION FINDINGS:
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LPA Spaeth interviewed the Activities Director, staff member and residents. LPA also reviewed the activities calendar for the last three months. During LPA's interviews of residents on the second floor, LPA observed four residents participating in an activity at 3:00 pm. Based upon LPA's interviews and observations, the above-referenced allegatio is unsubstantiated.

Exit interview conducted, and a copy of the signed report was given to the Administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PALM VISTA SENIOR LIVING
FACILITY NUMBER: 197610286
VISIT DATE: 01/04/2023
NARRATIVE
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Facility is not providing a variety of food and quantity necessary to meet the needs of the residents.- LPA interviewed six residents who stated the facility had run out of the main course over the last three months in three occasions. Also, all six residents stated the meals have been repeat meals each month. During LPA’s tour of the dining hall, LPA observed the bistro section only contained one fresh vegetable cup available for residents. This allegation is also substantiated.

Under Title 22 General Regulations, the following citation was issued and recorded on LIC 809D.

Exit interview was conducted, appeal rights discussed and a copy of the signed 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: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PALM VISTA SENIOR LIVING
FACILITY NUMBER: 197610286
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
01/11/2023
Section Cited
CCR
87666(a)
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87555 General Food Service Requirements (a) the total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents & shall meet the Recommended Dietary Allowance of the Food & Nutrition Board...This is evidenced by:
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Provide a plan which states to ensure the proper quantity of the food is available.
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Based upon LPA's resident interviews and LPA's observations, the facility failed to provide a variety and quantity of food for the residents.
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Deficiency Dismissed
Type B
01/11/2023
Section Cited
CCR
87555(b)(7)
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87555 General Food Service Requirements (b) the following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided.
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Dietician will provide input regarding the dietary needs of residents. Administrator will have Dietician approve menus upon their visits to ensure the dietary requirements are met. Also, Administrator will review documentation procedures with dining staff when residents chose to deviate from the dietary plan.
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Based upon LPA's interview of four residents, the facility did not provide healthty meal alternative to the residents which poses a health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4