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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006048
Report Date: 02/05/2025
Date Signed: 02/05/2025 04:37:16 PM

Document Has Been Signed on 02/05/2025 04:37 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CASA PALMAFACILITY NUMBER:
306006048
ADMINISTRATOR/
DIRECTOR:		KELADA, RENEEFACILITY TYPE:
740
ADDRESS:13382 KOOTENAY DRIVETELEPHONE:
(310) 941-7347
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY: 6CENSUS: 4DATE:
02/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:Administrator Renee KeladaTIME VISIT/
INSPECTION COMPLETED:
04:52 PM
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Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility for the purpose of conducting the required annual inspection. LPA was greeted and granted entry by care giving staff after explaining the purpose for the visit. Administrator (AD) Renee Kelada was notified via telephone and later arrived to assist with the inspection. LPA observed that Renee Kelada's Administrator certificate expired on December 14, 2024. However, LPA verified and confirmed that Renee Kelada submitted a renewal application to the Administrator Certification Bureau (ACB) on November 18, 2024.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for five non ambulatory and one bedridden resident, of which three may be on hospice. The facility is a single story home with four private resident bedrooms, three resident bathrooms, two of which are shared, one staff bathroom, a living room, a kitchen, a dining room, a sun room, a laundry room, and has an unattached two car garage. There is also a ADU and pool located in the backyard. LPA accompanied by the AD conducted a tour of the interior portion of the facility. On today's visit, LPA observed four residents in care, one of which is receiving hospice care, and two care giver staff present. LPA observed residents relaxing in the dining room and in their respective bedrooms. LPA observed the See Something, Say Something poster (PUB 475) mounted on the wall by the entryway of the facility. LPA inspected the four private resident bedrooms. LPA observed residents bedrooms to be clean and free of hazards. LPA observed the resident bedrooms had the required furnishing of a bed, a chair, and chest of drawers, and a lamp. LPA observed resident blankets and linens to be clean. LPA observed additional linens to be stored in a closet in the resident hallway. LPA inspected the three resident bathrooms. Resident bathrooms were clean. Bathrooms are equipped with grab bars and non-skid floors. Faucets and toilets were operational. Hot water temperature measured between 107.2 and 107.6 degrees Fahrenheit.

LPA observed the kitchen has a two day perishable and seven day nonperishable food supply on hand. LPA observed kitchen appliances to be clean and operational. CONTINUED ON LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CASA PALMA
FACILITY NUMBER: 306006048
VISIT DATE: 02/05/2025
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The five burner gas stove lights unassisted. LPA observed kitchen knives are stored in a locked kitchen cabinet. A fire extinguisher is located in the laundry room and it was observed the be charged and up to date on service. LPA observed chemicals and toxins to be stored in a locked cabinet in the laundry room. LPA tested the wired smoke detectors/carbon monoxide detectors which tested operational. The centrally stored medication is kept in a locked cabinet in the kitchen. A First Aid kit is stored in a locked cabinet in the kitchen and it was observed to have all the required components. The unattached two car garage is kept locked and inaccessible to resident in care. The garage is used for storage. LPA observed the facility has a three emergency food and water supply stored in the garage.

LPA and AD conducted a tour of the exterior portion of the facility. LPA observed the exterior portion to be clear of obstructions and hazards. LPA observed a shaded outdoor seating area with furniture for resident use. The perimeter gate on the west side of the facility is self-latching and can be opened in an evacuation. LPA observed the ADU located in the backyard is for staff use only and is kept inaccessible to resident's in care. LPA observed the pool in the backyard has a net for resident safety.

LPA reviewed all four resident files. All the required documentation were present and current in the resident files reviewed. LPA reviewed the four residents’ medication and medication records. LPA reviewed four staff files. All staff are background cleared and associated to the facility.

Based on today's observations, there are no deficiencies being cited per Title 22 of the California Code of Regulations. An exit interview was conducted with Administrator Renee Kelada and a copy of the report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
LIC809 (FAS) - (06/04)
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