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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006071
Report Date: 04/18/2022
Date Signed: 04/18/2022 04:22:11 PM

Document Has Been Signed on 04/18/2022 04:22 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: 108DATE:
04/18/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Administrator, Katherine TrevinoTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Jenifer Tirre made a unannounced visit for the purpose of a case management visit to follow up on an incident that happened in facility on 3/30/2022 between resident and staff member. LPA was granted entry to the facility and met with Administrator Katherine Trevino.

On 4/1/2022 LPA Tirre received incident report regarding Resident (R1) who had aggressive behavior towards staff member (S1). S1 was talking to another resident in hallway and R1 approached S1 and placed their hands on S1's throat. Local Police were called and came out to facility. Administrator stated Fullerton Police assessed R1 and didn't feel that R1 was a threat. Police asked S1 if they wanted to press charges and S1 stated no. R1 refused to go to Hospital for evaluation at the time of incident. Administrator contacted physician and R1's Family representative regarding incident. Physician issued order for R1 to be transferred to hospital for Psych Evaluation. Family Representative for R1 came out to facility on 4/6/2022 and talked to R1 about going to hospital. R1 left willingly with Family Representative and went to hospital for further evaluation of behavior. R1 is still currently in hospital. To Administrators knowledge R1 has had 2 episodes regarding physical aggressive behavior. LPA observed R1's physician report which states a diagnosis of Schizophrenia and Paranoid. Facility is awaiting for R1's reassessment paperwork. LPA spoke to S1 regarding incident. S1 stated this was first time they encountered an aggressive resident at facility. S1 went to their Physician and was put on modified duty and is receiving therapy as a result of incident.

LPA Tirre discussed with Administrator the terms and conditions regarding Eviction procedures. As a result of incident, Administrator is in process of conducting "How to de-escalate resident behavior training" for staff. Administrator has a video for staff to watch. Administrator will send over copy of staff signatures regarding training. Administrator to notify LPA Tirre of update regarding R1.

An exit interview was conducted with Administrator Trevino and copy of report along with LIC 811 was provided,


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SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2022
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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