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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700959
Report Date: 01/13/2022
Date Signed: 01/13/2022 12:40:27 PM

Document Has Been Signed on 01/13/2022 12:40 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:PALMS COURT IIFACILITY NUMBER:
312700959
ADMINISTRATOR:OGUNDIWIN, ADEOLAFACILITY TYPE:
740
ADDRESS:1419 CHAMPION OAKS DRTELEPHONE:
(559) 349-3057
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY: 6CENSUS: 4DATE:
01/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Adeola Ogundiwin, AdministratorTIME COMPLETED:
12:55 PM
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Licensing Program Analysts (LPAs) Michael Hood and Talwinder Bains arrived at the facility unannounced on 1/13/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPAs met with Administrator, Adeola Ogundiwin, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA Hood completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, and contacted facility to complete a facility risk assessment. LPAs ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask.

LPAs toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to: 6 bedrooms and 6 bathrooms for residents, common area, dining room, food supply, laundry room, outdoor area, and storage. In the areas toured no immediate health, safety, or personal rights violations were observed. LPAs and Administrator completed the infection control domain and facility was found to be in substantial compliance at this time.

No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2022
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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