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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610286
Report Date: 04/19/2024
Date Signed: 04/23/2024 08:33:21 AM

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
02/01/2024 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20240201160406
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: 63DATE:
04/19/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jeisy Pinoargote TIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff unlawfully evicted a resident
Staff is retaliating against a resident
Staff did not follow a licensed physician orders
Staff mishandled a resident's medications
Staff did not afford a resident privacy while in care
Staff unlawfully confiscated a resident's personal belongings
Staff overcharged a resident for a service not received
INVESTIGATION FINDINGS:
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On 4/19/2024 Licensing Program Analyst (LPA), Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth was met by Jeisy Pinoargote, Resident Care Director. LPA explained the purpose of this visit was to conduct interviews and present findings. LPA conducted a physical tour at 9:45am to 10:10 am.

The investigation consisted of the following: On 02/02/2024, LPA Spaeth initiated a complaint investigation. LPA reviewed resident files and interviewed two staff members. LPA received copies of the documentation. On 4/18/2024, LPA Spaeth reviewed resident documents, interviewed six residents. During today’s visit, LPA interviewed five (5) out of twenty-six (26) staff members.

Regarding the allegation: staff unlawfully evicted a resident and Staff is retaliating against a resident. It’s being alleged that a 60-day eviction notice was given to R1 in retaliation of R1 not paying for services
provided to R1. R1 was not available for interview and staff were unaware when the resident would be returning to the facility. The Administrator confirmed and provided documentation that R1 had not paid medication management amount due as of 8/22/2023. Also, R1 brought medication into the facility and

Cont'd 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024
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 2
Control Number 31-AS-20240201160406
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: 04/19/2024
NARRATIVE
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did not notify staff. However, the Administrator stated the notice was revoked and R1 and R1’s family members were notified. Five (5) of the twenty-six (26) staff members confirmed residents receive the care needed and staff do not retaliate against a resident in care. Six (6) of the sixty-three (63) residents confirmed staff have not retaliated against them. R1 was not available for an interview. The allegations are unsubstantiated.

Regarding the allegation: staff did not follow a licensed physician orders. It’s being alleged that R1 can manage their own medication. However, LPA observed the Physician’s report dated 2/26/2024 which states R1 needs assistance with medication distribution. Therefore the allegation is unsubstantiated.

Regarding the allegation: staff mishandled a resident’s medication. It’s being alleged that staff did not give a resident their pain medication. LPA interviewed two medical technicians who stated have never refused to give a resident their pain medication. LPA viewed R1’s medication log and observed medication was always given to the resident. Six (6) out of the sixty-three (63) residents confirmed they receive their medication each day. Therefore the allegation is unsubstantiated.

Regarding the allegation: Staff did not afford a resident privacy while in care and Staff unlawfully confiscated a resident's personal belongings . It’s being alleged that staff went into R1’s room and took medications from R1’s room. R1 was not available for interview. LPA interviewed the Administrator and the Resident Care Director who stated R1 invited them into R1’s room and observed the plastic sacks in R1’s room right in their sight. Both staff members observed the resident’s medications and R1 gave the medication to the Resident Care Director. Six out of the sixty-three (63) residents confirmed staff have always respected their privacy and staff have never confiscated a resident's personal belongings. Therefore the allegations are unsubstantiated.

Regarding the allegation: Staff overcharged a resident for a service not received. It is being alleged that R1 was informed they could not use a scooter within the facility. It was also alleged that the Administrator told R1 since R1 could not provide insurance for a scooter R1 would have to pay for staff members escortingR1 to the dining hall. R1 was unavailable for an interview. LPA Spaeth reviewed R1’s September, 2023 billing statement. LPA did not observe a charge for that type of service. LPA interviewed two residents who use scooters. The two residents (R4 and R5) confirmed they are allowed to have a scooter. Therefore the allegation is unsubstantiated.

Exit interview conducted and a copy of the signed report was given.

SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2