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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100404809
Report Date: 02/11/2025
Date Signed: 02/11/2025 04:51:58 PM

Document Has Been Signed on 02/11/2025 04:51 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:PALM VILLAGE RETIREMENT COMMUNITYFACILITY NUMBER:
100404809
ADMINISTRATOR/
DIRECTOR:		JIM HIGBEEFACILITY TYPE:
741
ADDRESS:703 WEST HERBERT AVENUETELEPHONE:
(559) 638-6933
CITY:REEDLEYSTATE: CAZIP CODE:
93654
CAPACITY: 262CENSUS: 164DATE:
02/11/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Administrator, Karly AlcantarTIME VISIT/
INSPECTION COMPLETED:
05:01 PM
NARRATIVE
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On 2/11/2025 Licensing Program Analyst (LPA) M. Garza completed an unannounced annual continuation visit. LPA met with Administrator, Karly Alcantar, explained reason and was permitted entry. LPA completed a health and safety check on residents in care.

Visit was a continuation for resident records review, hospice care plans, staff file reviews, incidental medical/ dental, medications and a completion of the care tool.

During visit the following items were observed: water temperature measured at 123.0 degrees F in restroom off common area. Deficiency cited per Title 22.

Exit interview completed with Administrator, Karly. A copy of this report, deficiency and appeal rights provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2025
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 02/11/2025 04:51 PM - It Cannot Be Edited


Created By: Mary Garza On 02/11/2025 at 04:12 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: 02/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
87303 Maintenance and Operation (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 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation. The Licensee did not comply with the section cited above in that the water temperature in downstairs restroom off common area measured at 123 degrees F. This poses a potential health safety and or personal rights risk to persons in care.
POC Due Date: 02/21/2025
Plan of Correction
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Administrator stated maintenence immediately turned down the water heater. Maintenence completes water temperature checks. Admnistrator stated they will complete a water temperature log for 2 weeks checking diffrent areas at least twice daily. Log will be provided to CCL as proof of correction.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:See Moua
LICENSING EVALUATOR NAME:Mary Garza
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2025


LIC809 (FAS) - (06/04)
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