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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700735
Report Date: 07/01/2021
Date Signed: 07/01/2021 05:30:47 PM

Document Has Been Signed on 07/01/2021 05:30 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:PALM VALLEY CARE IFACILITY NUMBER:
342700735
ADMINISTRATOR:SICAT, WINIFREDAFACILITY TYPE:
740
ADDRESS:8700 MILO COURTTELEPHONE:
(916) 686-2128
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 4DATE:
07/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:12 PM
MET WITH:Winifreda Sicat and Angelita DayoanTIME COMPLETED:
04:07 PM
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On 07/01/21 at 3:12 PM, Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a Required – 1 Year inspection. LPA Valerio introduced herself, stated the purpose of today’s visit, and was screened for COVID-19 symptoms and temperature taken prior to being allowed entry into the facility that is licensed to serve a total capacity of 6 clients. 

The physical and exterior plant was toured inside and outside to ensure the safety of the residents and compliance with Title 22 regulations. The facility does not have an approved LIC 808 Mitigation Plan. LPA Valerio went over the LIC 808 along with the infection control domain tool. Administrator Winifreda  and Co-Administrator Angelita expressed understanding of LIC 808 Mitigation Plan. Administrator will send LIC 808 to LPA by COB 07/02/21. LPA observed the facility to have a first aid kit. Hand washing signage and COVID - 19 informational signage posted at the front door and throughout the facility. The facility is able to designate and dedicated a Covid-19 bedroom and bathroom if needed.

The exterior has fence surrounding a pool that was observed to be locked. LPA Valerio observed the temperature inside the facility was measured at 73*F which is within the required range of 68 degrees F (20 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat the maximum shall be 30 degrees F (16.6 degrees C) less than the outside temperature.  The hot water was measured at 119.1 *F, which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations. Facility has food supplies: nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. The centrally stored medications area to be locked and inaccessible to clients. LPA Valerio observed fire extinguisher(s) with last check on 05/24/21, smoke and carbon monoxide detectors, central heating and air in the facility.

Per the California Code of Regulations, Title 22, Division 6,no deficiencies observed or cited.  Exit interview held, copy of report given to Administrator Winifreda and Co-Administrator Angelita.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2021
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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