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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006071
Report Date: 04/07/2022
Date Signed: 04/07/2022 02:28:44 PM

Document Has Been Signed on 04/07/2022 02:28 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: 105DATE:
04/07/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:06 PM
MET WITH:Katherine TrevinoTIME COMPLETED:
02:42 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
On this day Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to conduct a health and safety visit in conjunction with complaint visit 22-AS-20220405132859 . LPA was granted entry by staff. LPA identified herself and discussed the purpose of the visit and allegation with Administrator Katherine Trevino.

At 2:20 PM, LPA toured the facility along with Administrator Trevino. LPA observed residents relaxing in the common areas or resident rooms. Residents appeared clean and taken care of.


No health and safety concerns noted during today's visit.








Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2022
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 1