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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700735
Report Date: 05/08/2025
Date Signed: 05/08/2025 04:00:43 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/30/2025 and conducted by Evaluator Arvin Villanueva
COMPLAINT CONTROL NUMBER: 27-AS-20250430122806
FACILITY NAME:PALM VALLEY CARE IFACILITY NUMBER:
342700735
ADMINISTRATOR:ANGELITA DAYOANFACILITY TYPE:
740
ADDRESS:8700 MILO COURTTELEPHONE:
(916) 686-2128
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 6DATE:
05/08/2025
UNANNOUNCEDTIME BEGAN:
02:14 PM
MET WITH:Angelita DayoanTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff do not have adequate staffing.
INVESTIGATION FINDINGS:
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On 5/8/2025, Licensing Program Analysts Sommer Hayes and Arvin Villanueva (LPAs) arrived unannounced at this facility to conduct the initial complaint visit regarding the allegations noted above. During this visit, LPAs were met by staff on duty (S1) and stated the purpose of the visit. The Administrator Angelita Dayoan (AD) was notified and arrived shortly after. Present upon arrival was 6 residents with 1 staff on duty (S1).

During this visit, LPA conducted facility observation of food supplies including the refrigerator and freezer inside the garage, the refriegerator and freezer in the kitchen, and pantry. Duirng the inspection of the kitchen refrigerator, LPAs observed a medication (M1) inside the refrigeragor that is unlocked and accessible to residents in care. While inspecting the kitchen, LPAs observed the medication cabinet to be unlocked and accessible to residents in care. LPAs only observed S1 to be present upon arrival and was observed to be interacting with a resident in the TV area. Interview with S1 confirmed she is not a staff.

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Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 27-AS-20250430122806
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: PALM VALLEY CARE I
FACILITY NUMBER: 342700735
VISIT DATE: 05/08/2025
NARRATIVE
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Interview with AD revealed that S1 is in training and is not currently associated to this facility and has no background clearance to work at this facility. Review of Guardian confirms S1 is not associated to this facility. Interview with AD confirmed that the other staff (S2) went out of the facility and the other staff (S3) was at a personal appointment.

Upon arrival to this facility , there was no staff on duty except for S1 who was not cleared to work at this facility. Therefore the allegation that staff do not have adequate staffing has been SUBSTANTIATED.

A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are cited on the 9099D during this visit.

Licensee was provided a copy of their rights (LIC9058) and their signature acknowledges receipt of these rights. An exit interview was conducted and a copy of this report was provided.



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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20250430122806
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PALM VALLEY CARE I
FACILITY NUMBER: 342700735
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/09/2025
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement is not met as evidenced b:
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Per discussion, the Licensee will ensure qualified staff are present at the facility at all times.

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Based on interview and record review, the licensee did not comply with the regulation cited above. Upon arrival at the facility, there were no qualified staff members on duty, except for one individual who was not authorized to work at this location. This poses an immediate health, safety and personal risks to persons in care.
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Per discussion, the Adminsitrator agreed to submit a statement of understanding of the regulation cited relating to personnel requirments. Submit statement by POC due date.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4