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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100404809
Report Date: 05/26/2022
Date Signed: 05/26/2022 04:49:40 PM

Document Has Been Signed on 05/26/2022 04:49 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:PALM VILLAGE RETIREMENT COMMUNITYFACILITY NUMBER:
100404809
ADMINISTRATOR:JIM HIGBEEFACILITY TYPE:
741
ADDRESS:703 WEST HERBERT AVENUETELEPHONE:
(559) 638-6933
CITY:REEDLEYSTATE: CAZIP CODE:
93654
CAPACITY: 262CENSUS: 162DATE:
05/26/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:06 PM
MET WITH:Karely AlcantarTIME COMPLETED:
04:55 PM
NARRATIVE
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On 5/26/22, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Case Management visit to follow up on an incident reported to Department. It was reported that medication for R1 and R2 was dispensed and administered to the incorrect resident.

Facility immediately contacted primary physician, responsible parties and medication training was conducted with the staff person immediately after incident occurred. Additional medication training will be conducted with all staff as a review. Training records provided to LPA during facility visit.

Deficiencies cited on the attached 809 D in accordance to CCR Title 22.

Exit interview conducted. Appeal rights given. Facility report signed on site and a copy provided for facility records.



SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2022
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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Document Has Been Signed on 05/26/2022 04:49 PM - It Cannot Be Edited


Created By: Melinda Medina On 05/26/2022 at 04:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PALM VILLAGE RETIREMENT COMMUNITY
FACILITY NUMBER: 100404809

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/27/2022
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in
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Administrator immediately provided staff person with 1:1 medication training. All staff will be provided additional medication training. Training records provided to LPA during Case Management visit.
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obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. ***This was not be as evidenced by R1 and R2 were administered incorrect medication during AM shift.
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DEFICIENCY CLEARED AT TIME OF VISIT

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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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Melinda Medina
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022


LIC809 (FAS) - (06/04)
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