<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006071
Report Date: 01/10/2022
Date Signed: 01/10/2022 02:13:06 PM

Document Has Been Signed on 01/10/2022 02:13 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:PALMS RETIREMENT CENTERFACILITY NUMBER:
306006071
ADMINISTRATOR:BARRIENTOS, ELEANORFACILITY TYPE:
740
ADDRESS:312 N. ROOSEVELT AVETELEPHONE:
(626) 353-4710
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY: 144CENSUS: 117DATE:
01/10/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:LICENSEE, SONA BHATIATIME COMPLETED:
02:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPA's) Jenifer Tirre and Kimberly Lyman made an announced pre-licensing visit. LPA's identified themselves and discussed the purpose of the visit with Licensee Sona Bhatia and Administrator Ellen Barrientos. An initial application to operate a Residential Facility Care for the Elderly was submitted to CCL on 12/3/2021. There are 117 residents in care during today's visit. LPA's observed facility is following covid precaution guidelines.
LPA's Tirre and Lyman along with Licensee Sona Bhatia, Administrator Ellen Barrientos, Katherine Trevino Assistant Administrator toured the facility at 10:15 AM and observed the following:
Structure: Facility is a two story building housing 54 apartments in the assisted living and 18 apartments in the memory care unit. All assisted living apartments are currently double occupancy. Facility offers a library, dining room, TV room as well as two outside patios. Living Room/ Dining Room: Adequate seating is available in the main dining room. Bedrooms Residents: All rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Bathrooms: All resident bathrooms have a working toilet/ wash basin as well as grab bars and non-skid surface in the shower. Emergency Phone Numbers and Exit Plan: Posted in entrance of facility. Food Service: Facility has ample perishable and non perishable food supplies. All equipment is tested for temperature and are within acceptable ranges. LPA observed a posted menu with multiple choices for residents. Smoke Detectors: Carbon monoxide detectors were tested operational. Smoke detectors are tested in-house and documentation was provided by Compliance Fire Protection. Fire extinguishers are fully charged. Toxins: Secured and inaccessible to residents in care. Water Temperature: Tested and recorded between 84.0 and 134.4 degrees F in tested bathrooms. Emergency Supplies: LPA observed ample emergency food and water stored onsite in facility storage. Facility has a posted emergency menu in kitchen as well. CONT ON LIC 809C DATED
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2022
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: PALMS RETIREMENT CENTER
FACILITY NUMBER: 306006071
VISIT DATE: 01/10/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA'S observed the emergency disaster plan and facility has submitted the mitigation plan as well.Medications, First-Aid Kit & Book: LPA observed first aid kits and contained required elements. Medications are stored in locked medication carts. Facility uses hand written medication administration record. Resident & Staff File: LPA reviewed staff and resident files during the visit. Reading Material, Games, and Equipment: LPA observed the library room as well as posted activities in multiple locations. Outside areas: LPA observed two different outside shaded areas for residents, one in assisted living and one in memory care. Fire Clearance: Approved for 112 non-ambulatory residents and 32 bedridden residents on 10/18/2021. LPA observed the emergency chair adjacent to the staircase.

Licensee to address the following corrections by 1/31/2022:
  • Water temperature is out of compliance in the following rooms, 104,109,203,217,220 & 221. Please adjust water to be in compliance.
  • The following bath tubs were soiled in the following rooms, 113,115,122, & 210. Please clean tubs
  • The sink in Room 127 is separating from wall, please repair
  • The sink in Room 122 is backing up, please unclog
  • The sink in Room 113 has wooden beam used as support. Please repair
  • The bathroom door in Room 210 needs repairs
  • The grab bar in restroom 128 needs to be repaired properly and repair holes on wall
  • Let Us Know Poster is not regulation size, please have proper size poster 20x26 posted near entrance

The facility is not ready to be licensed. Licensee to contact LPA when corrections are complete.

Component III not conducted during visit due to facility Administrator currently running other licensed facilities.

An exit interview was conducted with Licensee and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2