PALMDALE SENIOR VILLA, LLC

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in two (2) out of two (2) bathrooms had a reading higher than 120 degrees which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/03/2026 Plan of Correction BATHROOM #1 127.3/BATHROOM #2 125.6. Administrator will lower water temperature and send LPA picture. Administrator wil create a water log for one week and send to LPA.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above laundry detergent,bleach, and other cleaning supplies were left on top of the washing machine unlocked which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/03/2026 Plan of Correction Staff removed cleaners at time of visit. Administrator will provide training with staff on section 87309(a) and send log to LPA by POC due date.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above comfort care medication was observed unlocked in refrigerator which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/03/2026 Plan of Correction Administrator will purchase lock box and send picture to LPA by POC due date.

Official classification

Type B

Official code

87470(c)

Regulation authority

CCR

What the official deficiency says

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above infection control plan was not avalible at time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/09/2026 Plan of Correction Administrator will email infection control plan to LPA by POC due date.

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above LPA was not provided INS at time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/09/2026 Plan of Correction Administrator will email a valid insurance to LPA by POC due date.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above LPA observed four (4) ripped chairs in kitchen and one broken towel bar in bathroom which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/09/2026 Plan of Correction Administrator will send LPA pictures of corrected items by POC due date.

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in Administrator and S2 did not have file at time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/09/2026 Plan of Correction Administrator will send completed files to LPA by POC due date.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above S2 did not have any training which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/09/2026 Plan of Correction Administrator will send S2's annual training to LPA by POC due date.

Official classification

Type B

Official code

87219(h)(2)

Regulation authority

CCR

What the official deficiency says

(h) The licensee shall provide sufficient space to accommodate both indoor and outdoor activities. Activities shall be encouraged by provision of: (2) Outdoor activity areas that are easily accessible to residents, protected from traffic, and have adequate shady areas. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above LPA did not observe a shaded outdoor area for residents to sit outside which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/09/2026 Plan of Correction Administrator will send LPA Pictures of shaded seating area by POC due date.

Official classification

Type B

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above residents did not have a current medication list from doctor with all medications and PRN's which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/09/2026 Plan of Correction Administrator will send a current list with alll active medication including PRN's to LPA by POC due date.

Official classification

Type B

Official code

87463(h)

Regulation authority

CCR

What the official deficiency says

(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above R3 did not have current medical exam LIC 602 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/09/2026 Plan of Correction Updated 602 will be sent to LPA by POC due date.

Official classification

Type B

Official code

1569.695(a)

Regulation authority

HSC

What the official deficiency says

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above emergency disater plan was not present at time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/09/2026 Plan of Correction Administrator will send 610 E to LPA by POC due date.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above facility did not have drill at time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/09/2026 Plan of Correction Administrator will send last drill conducted to LPA by POC due date.

Official classification

Type A

Official code

87458(c)(1)

Regulation authority

CCR

What the official deficiency says

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on review of resident's records, the licensee did not comply with the section cited above for one resident which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/18/2025 Plan of Correction The Licensee will send send a snapshot of the Medical Assessment for Resident #1 to LPA Spaeth

Official classification

Type B

Official code

87506(b)(17)(A)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (A) Section 87457, Pre-Admission Appraisal; This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's review of residents' files, the licensee did not comply with the section cited above for two residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/22/2025 Plan of Correction The Licensee will send a snapshot of the Pre-Admission Appraisal for two residents.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical & Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe & locked place…This is evidenced by: Based on LPA's observation, the licensee failed to ensure a resident's medication was locked in the refrigerator which poses an immediate health and safety risk to persons in care.

Official plan of correction

The Licensee purchased a locked drawer safe. The medication was locked in the drawer safe and placed in the refrigerator.

Deadline recorded: Oct 25, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA checking the water temperatures, the licensee did not comply with the section cited above in which the water temperature tested at 10:30 am and was 121.1 Degress F which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/29/2024 Plan of Correction During LPA's visit, the water temperature was adjusted and was tested at 11:45 am. The water temperature was 118.00 degrees F.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(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 Based on the LPA's observations, the staff room was unlocked and contained medication which was sitting out within the room, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/29/2024 Plan of Correction During LPA's visit, the room was locked by the caregiver at 10:25 am.

Official classification

Type A

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's review of the staff records, S1 and S2 did not have the required CPR/first aid training which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/03/2024 Plan of Correction S1 and S1 will complete the CPR/First aid training. The Administrator will send a snapshot of S1's and S2's completion of the CPR/First aid training.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observations, the refrigerator was not clean which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/29/2024 Plan of Correction LPA Spaeth observed the refrigerator was cleaned by the caregiver at 12:00 pm.

Official classification

Type B

Official code

87555(b)(26)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observation, there was not a one week supply of nonperishable foods and not an adequate supply of a two day supply of perishable foods which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/30/2024 Plan of Correction The Administrator will purchase a one week supply of nonperishable foods and a two day supply of perishable foods and send a snapshot of the food purchased. The Administrator will send the snapshot to LPA Spaeth as of 5/30/2024.

Official classification

Type A

Official code

87411(g)(1)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements – General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to criminal record review shall: (1) Obtain a California clearance or a criminal record exemption as required by law….This requirement is not met as evidenced by: Based on LPA's observations, an individual was present who had not cleared the criminal record clearance. This poses an immediate health & safety risk to the residents in care. $100 civil penalty has been assesed during this

Official plan of correction

LPA observed unknown person who is not associated in the facility. LPA is also unable to identify if the person has Criminal record clearance. LPA observed the person immediately left the facilty to obtain the clearance.

Deadline recorded: Jan 26, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87456(a)(3)

Regulation authority

CCR

What the official deficiency says

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's record review, the licensee did not comply with the section cited above in 2 out of 6 residents, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/21/2023 Plan of Correction The administrator agreed to submit a copy of the R1 & R2's LIC 602 on or before the POC date.

Official classification

Type B

Official code

87411(F)

Regulation authority

CCR

What the official deficiency says

All personnel including the administrator, shall be in good health and physically and mentally capable of performing assigned tasks. Good physical shall be verified by a health screening, including chest x ray or an intra dermal test by a physician not more than six (6) months to or seven (7) days after employment or licensure... This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's record review, the licensee did not comply with the section cited above in 2 out 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/21/2023 Plan of Correction The administrator agreed to obtain health screening for S1 & S2 on or before the POC date and submit a copy to CCL