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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209060
Report Date: 11/22/2022
Date Signed: 11/22/2022 11:18:45 AM

Document Has Been Signed on 11/22/2022 11:18 AM - 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 GARDEN RETIREMENT HOME & DEMENTIA CAREFACILITY NUMBER:
107209060
ADMINISTRATOR:KOPACZ, CAMALAH S.FACILITY TYPE:
740
ADDRESS:8891 E. HERNDON AVE.TELEPHONE:
(559) 324-1733
CITY:CLOVISSTATE: CAZIP CODE:
93619
CAPACITY: 6CENSUS: 6DATE:
11/22/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Camalah Kopacz, AdministratorTIME COMPLETED:
11:35 AM
NARRATIVE
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Licensing Program Analyst (LPA) L. Cabrera conducted a subsequent Case Management visit to discuss information obtained from a complaint investigation (24-AS-20220822160531) conducted on 08/24/2022. Per interviews and records reviewed, facility did not have two exception requests and physician order records for all residents that require full bed rails.

Deficiencies were cited on the LIC809D. Exit interview conducted, and a copy of Appeal Rights were provided to Administrator.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 11/22/2022 11:18 AM - It Cannot Be Edited


Created By: Lady Cabrera On 11/22/2022 at 09:08 AM
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 GARDEN RETIREMENT HOME & DEMENTIA CARE
FACILITY NUMBER: 107209060

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/02/2022
Section Cited
CCR
87608(a)(3)

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87608 Postural Supports (a)Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care...Postural supports may be used under the following conditions (3)A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
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LPA provided Postural Supports regulation to the Administrator. Licensee will submit exception requests with physician’s orders for all resident’s that require full bed rails to CCL by 12/02/2022.

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Based on interviews and records reviewed, Licensee did not submit exception requests for resident that require full bed rails, which poses a potential health, safety or personal rights risk to persons in care.
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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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Lady Cabrera
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2022


LIC809 (FAS) - (06/04)
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