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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700959
Report Date: 11/21/2024
Date Signed: 11/21/2024 02:38:07 PM

Document Has Been Signed on 11/21/2024 02:38 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:PALMS COURT IIFACILITY NUMBER:
312700959
ADMINISTRATOR/
DIRECTOR:
OGUNDIWIN, ADEOLAFACILITY TYPE:
740
ADDRESS:1419 CHAMPION OAKS DRTELEPHONE:
(559) 349-3057
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY: 6CENSUS: 3DATE:
11/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Wendy Ulaba and Adeola OgundiwinTIME VISIT/
INSPECTION COMPLETED:
03:00 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 Analyst (LPA) Cassandra Mikkelson arrived unannounced to conduct an annual inspection. LPA met with Wendy Ulaba and Adeola Ogundiwin during today's inspection.

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed six (6) resident rooms and two (2) common area bathrooms. LPA observed rooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and ready for resident use and hot water temperature was observed to be 113.0 degree F.

LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two day perishable and (7) seven day non-perishable food supply on hand. Smoke detectors and carbon monoxide detectors are maintained in care home. First aid kit is maintained and ready for emergency use. LPA checked medication storage and found medications to be locked away and inaccessible to the residents. LPA reviewed three (3) resident files and two (2) staff files. Facility has a current copy of certificate of liability insurance and LPA requested a copy.

As a result of this visit, no deficiencies were cited.

Exit interview was conducted with Adeola Ogundiwin. A copy of this report provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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 8