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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006071
Report Date: 03/19/2024
Date Signed: 03/19/2024 03:15:59 PM

Document Has Been Signed on 03/19/2024 03:15 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: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: 118DATE:
03/19/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Administrator, Erin RehbeinTIME COMPLETED:
02:30 PM
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On this day Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced Case Management visit to follow up on an Incident that occurred on March 14, 2024. LPA discussed purpose of visit with Administrator Erin Rehbein.

On March 19, 2024 Department received a Self reported SOC 341 Report from Facility. Facility reported that an incident occurred between two residents on March 14, 2024. Staff reported to Administrator that in passing in facility hallway, Resident 1 (R1) approached Resident 2 (R2). Staff reported that R2 was rubbed by R1 on the right side thigh and butt area. Staff also reported that same incident occurred a second time on March 16, 2024. Upon learning of incident Administrator had staff member (S1) translate to R2 regarding incident. Based on translation S1 stated that they asked R2 if they were touched inappropriately to which R2 shook their head "no". S1 asked R2 if they were hurt and R2 stated "Ok" in Vietnamese. Based off interviews with staff, Administrator stated that they spoke to R1 regarding incident and R1 claimed they "did not know anything". Facility had sent out R1 to hospital for Psych Evaluation. R1's face sheet, Appraisal, and Emergency info all state that R1 has a health history of Dementia and Schizophrenia. R1's Physician's Report dated November 30, 2023 has diagnosis of Pneumonia, COPD and mild cognitive impairment. At time of visit R1 not present for interview. R1 has not returned to facility. Administrator states upon R1's discharge they plan to work with conservator regarding plan of care moving forward.

During visit, with the help of staff 1, LPA attempted interviewing R2 regarding incident, upon attempt R2 nodded head "yes" when asked if they were okay. R2 was asked if they had been touched and R2 nodded "no". R2 was unable to verbally communicate due to a language barrier. LPA observed R2's Physician Report which has Schizophrenia listed as primary diagnosis and lists Cerebral Infarction as secondary diagnosis. R2's Resident's Appraisal dated 11/30/23 states R2 has a communication deficit and unable to communicate needs clearly.
CONTINUED ON 809C
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2024
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: PALMS RETIREMENT CENTER
FACILITY NUMBER: 306006071
VISIT DATE: 03/19/2024
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Administrator contacted responsible parties, Licensing, Ombudsman and Police regarding incident.
LPA received copies of resident physician's reports and appraisals.

An exit interview was conducted with Assistant Administrator Kathleen Tamondong and a copy of report was left at facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
LIC809 (FAS) - (06/04)
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