197610326-2-23-2024-31-AS-MSPH-D2R38K-20240223170136

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610326
Report Date: 02/23/2024
Date Signed: 02/23/2024 05:01:47 PM

Document Has Been Signed on 02/23/2024 05:01 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	MONDELL PINE MANOR II		FACILITY NUMBER:	197610326
ADMINISTRATOR:	VIRAY, JEROME		FACILITY TYPE:	740
ADDRESS:	39040 MONDELL PINE AVENUE		TELEPHONE:	(818) 332-6150
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY:	6	CENSUS: 5	DATE:	02/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Stephanie Domingo		TIME COMPLETED:	02:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by the caregiver. The Administrator Stephanie Domingo arrived at 10:00 am. LPA stated the purpose of the visit was to conduct an annual inspection. The Administrator confirmed there are five residents living in the facility. The facility is licensed for six (6) non-ambulatory residents. Two (2) of the six (6) can be bedridden residents.

LPA Spaeth and the Administrator toured the facility at 10:15 am until 11:00 am..

Common Areas – The family room, dining room, and kitchen are combined. The family room was furnished with comfortable seating and a television. The dining room contained a dining room table and chairs.

Medications: LPA observed the resident medications, first aid kit, and PPE supplies were safely locked in a kitchen cabinet.

Kitchen – LPA observed a two day supply of perishable food and a seven day supply of non-perishable food items. The fire extinguisher was located near the kitchen and was operable. The Administrator opened a kitchen cabinet but observed the lock using a magnet did not properly work. LPA stated to the Administrator that a secure lock will need to be installed. Cleaning solutions were locked underneath the kitchen sink.

Laundry Room – The laundry room door has a key-punch lock system. The door was slightly opened and was not securely locked. LPA observed the washer/dryer and the laundry detergent.

Continued on 809-C

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

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: MONDELL PINE MANOR II	FACILITY NUMBER: 197610326
	VISIT DATE: 02/23/2024

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Garage –The garage was locked. The staff room is located within the garage area.

Resident Rooms: There are four resident rooms which were furnished with a bed, linens, night stand, lamp and chair. The rooms were neat and clean. LPA Spaeth observed the resident rooms contain a sprinkler system.

Bathrooms: There are three bathrooms in the facility. The bathrooms contained hand soap, paper towels, grab bars, and slip resistant mats. At 10:45 am, LPA observed a Lysol spray, cleaning solution stored underneath the bathroom sink and not securely locked. LPA Spaeth tested the water temperature in the bathroom located in a resident's room. The temperature was recorded to be 118.0 Degrees F. LPA observed the clean linens were located in a cabinet within the staff bathroom.

Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. The side gate of the house was closed and was not locked. Comfortable seating is also located in the backyard.

Smoke/Carbon Monoxide Detectors: The smoke/carbon monoxide detectors were tested at 10:55 am and were operable.

LPA reviewed resident files at 11:00 am until 11:50 am. LPA Spaeth observed resident 1 and resident 5 did not contain the Physician's Report. LPA reviewed staff records at 11:50 am until 12:20 pm. LPA viewed a resident's medication at 12:20 until 12:30 pm.

Based upon LPA's observations and based upon Title 22 Regulations, the following deficiencies are substantiated. (See 809-D page).

Exit interview conducted, appeal rights discussed, and a copy of the signed 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: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/23/2024 05:01 PM - It Cannot Be Edited

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: MONDELL PINE MANOR II	FACILITY NUMBER: 197610326
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, the licensee did not comply with the section cited above in one instance when al cleaning solution was not locked in a bathroom cabinet which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/23/2024
	Plan of Correction
1 2 3 4	During LPA's visit, LPA observed the Administrator safely locked the cleaning solution in the locked kitchen cabinet underneath the kitchen sink.

Type A

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's resident record review, LPA observed the Physician's Report was missing from R1 and R5's file. The licensee did not comply with the section cited above in two out of five residents' files which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/04/2024
	Plan of Correction
1 2 3 4	The Administrator will send a copy of R1 and R5's physician's report to LPA Spaeth via email

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: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 02/23/2024 05:01 PM - It Cannot Be Edited

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: MONDELL PINE MANOR II	FACILITY NUMBER: 197610326
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observations, the licensee did not comply with the section cited above. LPA observed the kitchen cabinet lock was not working where medications are stored. This poses poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/26/2024
	Plan of Correction
1 2 3 4	The Administrator will send a snapshot of the newly installed lock to the medication cabinet to LPA Spaeth via email.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

LIC809 (FAS) - (06/04)

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