Palmdale Senior Villa

Type of visit: POC

Licensing Program Analyst (LPA) Evelin Rios arrived to this facility to conduct and unannounced POC visit for citations issued on 08/02/2026. LPA rang the door bell and was greeted by a staff member. Staff contacted the administrator Jojomaureli B. Salamero by telephone and LPA informed the administrator the purpose of the visit. Original Citations and POC's with results of the POC visit are as follows: 87303(e)(2) Maintenance and Operation: BATHROOM #1 127.3/ BATHROOM #2 125.6. POC: Administrator will lower water temperature and send LPA picture. Administrator will create a water log for one week and send to LPA by POC due date 08/03/26. Staff provided LPA a copy of the water log for testing conducted by staff around 8 AM. Log has temperatures within range. At around 3:30 PM LPA tested the water in Bathroom #1 and Bathroom #2, temperatures read 119 degrees Fahrenheit. POC cleared today. 87309(a) Storage Space and Access: Laundry detergent, bleach, and other cleaning supplies were left on top of the washing machine unlocked. POC: Administrator will provide training with staff on section 87309(a) and send log to LPA by POC due date 08/03/2026. LPA reviewed a copy of training. POC cleared today. 87465(h)(2) Incidental Medical and Dental Care Services: Comfort care medication was observed unlocked in refrigerator. POC: Administrator will purchase lock box and send picture to LPA by POC due date 08/03/26. LPA observed two lock boxes in the refrigerator. POC cleared today. (Continue to LIC809-C) 87470(c) Infection Control Requirements: Infection control plan was not available at time of visit. POC: Administrator will email infection control plan to LPA by POC due date 08/09/26. LPA reviewed a copy of the facility's Infection Control Plan. POC cleared today. H&S Code 1569.605 Other Provisions: Liability insurance was not provided at time of visit. POC: Administrator will email a valid insurance to LPA by POC due date 08/09/26. LPA reviewed a copy of the Liability Insurance. POC cleared today. 87303(a) Maintenance and Operation: LPA observed four (4) ripped chairs in kitchen and one broken towel bar in bathroom. POC: Administrator will send LPA pictures of corrected items by POC due date 08/09/26. LPA observed a new towel rack and the four chairs had new upholstery. POC cleared today. 87412(a) Personnel Records: Administrator and S2 did not have file at time of visit. POC: Administrator will send completed files to LPA by POC due date 08/09/26. LPA reviewed administrator's and staff Anthony Castro's file. POC cleared today. H&S 1569.625(b)(2) Other Provisions: S2 did not have any training. POC: Administrator will send S2's annual training to LPA by POC due date 08/09/26. LPA reviewed staff Anthony Castro's training. POC cleared today. 87219(h)(2) Planned Activities: LPA did not observe a shaded outdoor area for residents to sit outside. POC: Administrator will send LPA Pictures of shaded seating area by POC due date 08/09/26. LPA observed an outdoor umbrella. POC cleared today. (Continue to LIC 809-C) 87465(a)(6) Incidental Medical and Dental Care Services: Residents did not have a current medication list from doctor with all medications and PRN's. POC: Administrator will send a current list with all active medication including PRN's to LPA by POC due date 08/09/26. LPA reviewed resident's medication list. POC cleared today. 87463(h) Reappraisals: R3 did not have current medical exam LIC 602. POC: Updated 602 will be sent to LPA by POC due date 08/09/26. LPA reviewed an appointment confirmation provided between the administrator and R3's responsible person indicating an appointment to update LIC602 has be scheduled for August 14, 2026. Administrator will send updated LIC602 to the Department following the appointment. POC extension granted. POC due date is now 08/18/26. H&S 1569.695(a) Other Provisions: Emergency disaster plan was not present at time of visit. POC: Administrator will send 610E to LPA by POC due date 08/09/26. LPA reviewed LIC610E. POC cleared today. H&S 1569.695(c) Other Provisions: Facility did not have drill at time of visit. POC: Administrator will send last drill conducted to LPA by POC due date 08/09/26. LPA reviewed Fire drills conducted. POC cleared today. Administrator emailed LPA copies of documents reviewed during todays visit. LPA will update facility's file in the Regional office. No immediate health and safety issues observed. Exit interview conducted. Copy of report provided to staff member.the state’s words, verbatim · CDSS document, Aug 12, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met with caregiver Ivy Ceraide and explained the purpose of today’s visit. Administrator Jojomaureli Salamero was notified by telephone. Facility is licensed to serve Residents ages 60 and over. Approved fire clearance for 5 non-ambulatory, two (2) residents in room #1, two (2) residents in room #4, and one (1) resident in room #2. One (1) bedridden in room #3. Staff room #5 87705 compliant. Hospice waiver for 2 residents. The facility is single story house located in a residential neighborhood in the city of Palmdale. LPA toured the facilities physical plant, indoor and outdoor. The facility has a formal living room/dining room, four (4) resident bedrooms, one (1) staff room, two (2) bathrooms (one of which is in bedroom #1), kitchen with dining area and second living room, laundry area, and attached garage used for storage. LPA toured the facility and observed the following: All resident bedrooms have the required furniture and bedding. There is extra clean linen and towels in hallway cabinets. Smoke detectors/carbon monoxide detectors were observed throughout facility. The facility has one (1) fire extinguisher which is kept in kitchen. LPA observed four kitchen chairs to all be torn. Cleaning supplies and toxic substances were observed to be accessible to residents in care in laundry area in top of washing machine. Sharps are locked in drawer in kitchen. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 40 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. LPA observed a box of unlocked comfort care medication in refrigerator. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured not between the required range of 105-120 degrees F. Bathroom #1 127.3 and bathroom #2 125.6. There is a broken bar in bathroom #2. The facility does not have a swimming pool or large body of water. LPA did not observe a shaded seating area for the residents. Passageways and exits are free of obstruction. Two (2) out of four (4) staff files were reviewed and included Criminal clearance record, required training TB. Administrator and S3 files was not available at time of visit. Three (3) resident files were reviewed and R1 was missing current physician report LIC 602. Infectious control plan, emergency disaster plan, and drill were not reviewed and will be emailed to LPA. Administrator will email current liability insurance. Residents did not have a current list of medications from physician. Medications are centrally stored in living room in a licked cabinet. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during today’s visit will be documented on LIC809-D. Exit interview was held and a copy of the report with appeal rights was given.the state’s words, verbatim · CDSS document, Aug 2, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by the caregiver. The Administrator was called and LPA stated the purpose of the visit is to conduct an annual inspection. The facility is licensed for five non-ambulatory residents and one bedridden resident. LPA confirmed there are five residents in the facility. LPA and the caregiver toured the facility at 10:15 am until 10:55 am. Kitchen - LPA Spaeth observed a two-day supply of perishable food and a seven day supply of non-perishable food. The knives were locked in a kitchen drawer. The cleaning solutions were locked underneath the kitchen sink. The fire extinguisher is located near the kitchen and is operable. Common Areas –The living room and dining room are combined and contained comfortable seating along with dining room table and chairs. The family room contained comfortable seating and a television. Residents’ Rooms – The rooms contained a bed, linens, night stand, lamp, chest of drawers and a closet. Continued on 809-C Bathroom – The two bathrooms contained grab bars, slip resistant mats, paper towels and a covered trash can. The water temperature was tested at 10:55 am and was 116.4 degrees F. Backyard –The backyard contained a shaded area. The gate leading from the backyard to the front yard was not locked. Medications - The medications were locked in a cabinet located in the living room. The first aid kit was also locked in the cabinet. Laundry Area – The washer and dryer are located in a laundry area. The laundry detergent was located in the locked garage. Smoke/Carbon Monoxide Detectors - The smoke/carbon monoxide detectors were tested at 10:56 am and were properly working. Egress System -LPA Spaeth observed the egress system was working when exiting the facility. Residents’ Records -LPA reviewed residents' records at 11:15 am until 12:15 pm. LPA observed resident files were incomplete. LPA Spaeth spoke to the Administrator by phone and explained to the Administrator what documents were needed in the residents' files. Staff Records - LPA reviewed five records at TIME until TIME. Based upon LPA's observations, the following deficiencies were cited (see 809-D page). Exit interview conducted, appeal rights discussed and a copy of the report was given.the state’s words, verbatim · CDSS document, Apr 16, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced case management visit and was greeted by the caregiver. LPA Spaeth received and reviewed an incident report from the facility dated 2/18/2025 and a death report dated 2/21/2025. LPA spoke to the Administrator, Jojomaureli Salamero by phone. LPA Spaeth stated the purpose of the visit was to tour the facility and review a resident's file. LPA Spaeth and the caregiver toured the facility at 10:15 am until 10:40 am. LPA Spaeth interviewed the caregiver at 10:40 am until 10:55 am. LPA Spaeth reviewed the resident's records at 10:55 am until 11:35 am. There are no deficiencies to report at this time. Exit interview conducted and a copy of the report was given.the state’s words, verbatim · CDSS document, Feb 27, 2025

Allegation investigated: Staff does not dispose deceased resident's medications. Staff does not ensure resident's ingest medications. Residents have access to a lighter. Residents have access to scissors and knives.

This is an amended copy of the report previously issued on 10/25/2024. This report supersedes reports previously issued. The findings for this complaint remain the same. On 10/25/2024 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 the caregiver. The Administrator was called and LPA explained the purpose of the visit was to interview the residents and present the findings. The Administrator stated the caregiver may sign the report. Continued on 9099-C Unsubstantiated This is an amended copy of the report previously issued on 10/25/2024. This report supersedes reports previously issued. The findings for this complaint remain the same. LPA conducted a physical tour at 10:15 until 10:30 am. LPA interviewed four out of the five residents at 10:30 am until 11:15 am. The investigation consisted of the following: On 9/21/2023 LPA Spaeth initiated a complaint investigation for the allegation(s) listed above. LPA Spaeth toured the facility at 2:15 am until 2:30 pm and interviewed the Administrator at 3:00 pm. Regarding the allegation: Staff does not dispose deceased resident's medications: it’s being alleged a deceased resident’s medication was in an unlocked cabinet and was not properly disposed by staff. On 9/21/2023 at 2:30 pm, LPA did not observe a deceased resident’s medication stored in an unlocked kitchen cabinet. Regarding the allegation: Staff does not ensure resident's ingest medications. It’s being alleged that staff did not observe residents taking their medication. LPA Spaeth interviewed the Administrator and staff member (S1) on 9/21/2024. The Administrator and S1 confirmed when distributing resident’s medications, they both observe residents taking their medications. LPA Spaeth interviewed four out of the five residents. The four residents interviewed (R1, R2, R3 and R4) unanimously confirmed staff observe them taking their medication. R4 was unavailable. Regarding the allegation: Residents have access to a lighter: it’s being alleged that a lighter was stored in an unlocked cabinet. During LPA’s tour of the facility on 9/21/2023, LPA did not observe a lighter stored in an unlocked cabinet. Regarding the allegation: Residents have access to scissors and knives: it’s being alleged that a knife and scissors were stored in an unlocked drawer. During LPA’s tour of the facility on 9/21/2023, LPA did not observe such items in an unlocked cabinet. Based upon LPA's observations, the above allegations are unsubstantiated. Exit interview conducted and a copy of the report was given.the state’s words, verbatim · CDSS document, Oct 25, 2024 · control 31-AS-20230915113421

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Oct 25, 2024

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.the state’s words, verbatim · CDSS document, Oct 25, 2024

Plan of correction: The Licensee purchased a locked drawer safe. The medication was locked in the drawer safe and placed in the refrigerator.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Spaeth conducted an unannounced visit and was greeted by the caregiver. The Administrator was called and arrived at 10:00 am. LPA stated the purpose of the visit is to conduct an annual inspection. The facility is licensed for five non-ambulatory residents and one bedridden resident. LPA confirmed there are five residents in the facility. LPA and the Administrator toured the facility at 10:00 am until 10:30 am. Kitchen - The refrigerator was dirty and LPA explained the appliance needs to be clean at all times. LPA did not observe an adequate supply of perishable and non-perishable food. Common Areas –The living room and dining room are combined and contained comfortable seating along with dining room table and chairs. The family room contained comfortable seating and a television. Residents’ Rooms – The rooms contained a bed, linens, night stand, lamp, chest of drawers and a closet. Bathroom – The bathroom contained grab bars, slip resistant mats, paper towels and a covered trash can. The water temperature was tested at 10:15 am and was 121.1 degrees F. Backyard –The backyard contained comfortable seating. The gate leading from the backyard to the front yard was not locked. Medications - The medications were locked in a cabinet located in the living room. The first aid kit was also locked in the cabinet. Laundry Area – The washer and dryer are located in a laundry area. The laundry detergent was located in the locked garage. Egress System -LPA Spaeth observed the egress system was working when exiting the facility. Smoke/Carbon Monoxide Detectors - The smoke/carbon monoxide detectors were tested at 10:30 am and were properly working. Residents’ Records -LPA reviewed residents' records at 10:30 am until 11:00 am and LPA did not observe any issues with the records. Staff Records - LPA reviewed five staff records at 1:15 pm until 2:15 pm. Based upon LPA's observations, the following deficiencies were cited (see 809-D page). Exit interview conducted, appeal rights discussed and a copy of the report was given.the state’s words, verbatim · CDSS document, May 29, 2024

Allegation investigated: Facility staff are not ensuring that food is of good quality.

On 01/26/2024 Licensing Program Analyst (LPA) Melissa Spaeth, initiated a complaint investigation for the allegation(s) listed above. LPA Spaeth was greeted by the Administrator. LPA Spaeth explained the purpose of the visit was to investigate a complaint. LPA requested the following documents: 1) Resident roster; and 2) staff roster. LPA Spaeth received the documents during the visit. LPA and the Administrator toured the facility at 10:45 am until 11:15 am. LPA interviewed residents at 11:15 am until 11:45 am. It was alleged that the milk in the facility refrigerator was expired and had been previously frozen. It was also reported that the milk is thrown away one week after it has been thawed but the facility did not track the dates to determine when the milk should be thawed. Unsubstantiated At 10:45 am, LPA observed the expiration date for the milk within the refrigerator was 01/30/2024. At 10:55 am, LPA observed a gallon of milk was in the freezer. The expiration date was 1/30/2024. LPA observed the gallon contained an additional black marker reminder with the expiration date marked in large letters. The Administrator stated the milk will be used before the expiration date. The residents drink a gallon of milk every week. The Administrator stated milk is purchased every two weeks. LPA Spaeth observed there was no expired food within the pantry or the refrigerator. LPA interviewed three of the four residents. Residents 1, 2, 3, and 4 unanimously agreed the food is good quality. Residents 1, 2, 3 and 4 stated the facility staff has never served spoiled milk or spoiled food. R5 was sleeping during LPA’s visit. Based upon LPA Spaeth’s observations and interviews, the allegation, facility staff are not ensuring that food is of good quality is unsubstantiated. Exit interview conducted and a copy of the report was given.the state’s words, verbatim · CDSS document, Jan 26, 2024 · control 31-AS-20240124091144

Type of visit: Case Management - Deficiencies

On 1/26/2024, Licensing Program Analyst (LPA), Melissa Spaeth conducted an unannounced complaint visit regarding Complaint #31-AS-20240124091144. During the visit, LPA observed a caregiver working at the facility who had not obtained a California clearance or a criminal record clearance. The Administrator stated the individual was shadowing the Administrator but had not obtained the required clearance. Per CA Code of Regulations, Title 22, the following deficiencies were issued (See 9099-D). Exit interview conducted, appeal rights discussed, and a copy of the report was given.the state’s words, verbatim · CDSS document, Jan 26, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(g)(1) · Plan of correction due date: Jan 26, 2024

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 thisthe state’s words, verbatim · CDSS document, Jan 26, 2024

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.