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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700735
Report Date: 06/18/2025
Date Signed: 06/18/2025 04:26:24 PM

Document Has Been Signed on 06/18/2025 04:26 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:PALM VALLEY CARE IFACILITY NUMBER:
342700735
ADMINISTRATOR/
DIRECTOR:		ANGELITA DAYOANFACILITY TYPE:
740
ADDRESS:8700 MILO COURTTELEPHONE:
(916) 686-2128
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
06/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Angelita DayoanTIME VISIT/
INSPECTION COMPLETED:
01:23 PM
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On 6/18/2025 Licensing Program Analysts Sommer Hayes and Arvin Villanueva (LPAs) arrived at this facility unannounced to conduct an annual inspection. LPA initially met with staff on duty, and stated the purpose of the visit. The Licensee/Administrator, Angelita Dayoan (AD), was notified of the visit and arrived shortly after.
Present during this visit were 6 residents in care with 2 staff on duty. During this visit, LPA observed one resident at the dining table having a meal. One resident in the living room watching TV with their visitor. Other residents were in their bedrooms. One outside agency staff arrived during the visit.
LPAs evaluated the physical plant with AD to ensure the health and safety of the residents in care. The facility is a one-story home located in a residential neighborhood. Areas inspected are including but not limited to the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas.
LPAs observed common areas to be clean and free from debris and obstructions. All 6 resident bedrooms were observed to be fully furnished and have enough space to accommodate resident belongings. Three bathrooms were observed to be well maintained and sanitized. Facility maintains an adequate amount of linen supplies. The room temperature was observed at 75 degrees Fahrenheit upon arrival. Hot water temperature was taken in 2 resident bathrooms and were measured between 127 and 133 degrees Fahrenheit.
In the kitchen area, the LPAs observed a small live cockroach inside one of the sliding drawers. Additionally, during an inspection of the kitchen freezer, two dead cockroaches were found at the bottom. In an interview, the AD stated that pest control services are used. AD provided pest control service agreement from November 2023 to October 2024; however, AD was unable to provide continuing pest control contract or any supporting documentation as proof of services being done after October 2024. One of the kitchen cabinet door was observed to be falling off when this LPA opened the door. During this visit, a person came to fix the cabinet door. Inside the refrigerator, LPAs observed a locked black metal container.
{Con't to LIC809-C}
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: PALM VALLEY CARE I
FACILITY NUMBER: 342700735
VISIT DATE: 06/18/2025
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The facility maintains nonperishable foods for a minimum of 7 days and perishable food for 2 days. Pantry was also observed to have adequate food supplies. Inside the pantry, LPAs observed a container which read CBD gummies on the top shelves. Per interview with staff on duty, that belongs to one of the staff. Staff on duty immediately took the CBD gummies. The garage houses additional freezers and refrigerators. Additional food supplies were observed in the garage. In one of the cabinet that is unlocked, contained food supplies and at the bottom shelf of the cabinet, LPAs observed chemicals including paint containers and Flex Seal aerosol spray bottle. Staff on duty immediately removed the items and placed them inside a locked cabinet.

Fire extinguishers are maintained in the facility and were observed to be fully charged and were last serviced on 5/6/25. Medications, cleaning supplies, and sharp objects were observed to be locked and inaccessible to residents in care, except those found inside the garage cabinet. Smoke detectors were observed to be in each bedrooms and hallways and at least one carbon monoxide detector was observed.

Outdoor area was inspected. Facility has 1 side gate exits. Facility has a swimming pool which was observed to be gated, locked with padlock and not accessible to residents in care. Gate and fences were observed to be in good repair at this time. LPAs observed one window screen and one sliding door screen to be in disrepair. Advisory was provided to AD to make necessary repairs.

Review of 6 resident files (R1, R2, R3 R4, R5, R6) include review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status. Each resident binder had PRN authorization letter on file.

A medication review for two residents was conducted by the LPAs and the AD, which included an assessment of physician orders for over-the-counter medications. During the review of Resident R5's medications, the LPAs identified three medications that did not comply with the physician’s orders. The medication Docusate (Stool Softener) was prescribed at 250 mg, but the facility only had 100 mg capsules available. According to interviews with the AD and staff, they administer two capsules, which still results in a 50 mg shortfall. Additionally, Turmeric was prescribed at 450 mg, but the facility had 500 mg capsules. Krill oil was ordered at 500 mg, while only 400 mg capsules were on hand. Furthermore, one of R5's medications, Metformin, was found to be expired.

{Con't to LIC 809-C}
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: PALM VALLEY CARE I
FACILITY NUMBER: 342700735
VISIT DATE: 06/18/2025
NARRATIVE
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Review of 3 staff files (S1, S2, and S3) include review of background clearance, First Aid/CPR certificate, Health Screen, Initial and Ongoing Training. Administrator Certificate is current. No issues were noted at this time.

Facility conducts quarterly disaster drill. Facility has a dementia and infection control plan.

Administrator to submit copy of current Liability Insurance Certificate, LIC500 and LIC308 to the Department.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were observed during today's visit.
The following deficiencies were observed during this visit:
  • Cockroaches we observed inside a sliding drawer and inside the kitchen freezer.
  • Hot water temperature in 2 resident bathroom faucets were between 127 and 133 degrees Fahrenheit.
  • Container of CBD Gummies belonging to staff was observed inside the food pantry.
  • 3 medications were not in compliance with doctor's orders.
  • One resident medication was observed to be expired.
  • Chemicals was being stored with food supplies inside a cabinet in the garage.

Exit interview was conducted and a copy of the report was provided upon exit.

Per California Code of Regulations, Title 22, Division 6, Chapter 6, deficiencies were observed during this visit. An exit interview was held, and a copy of this report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 06/18/2025 04:26 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 06/18/2025 at 01:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PALM VALLEY CARE I
FACILITY NUMBER: 342700735

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Hot water temparature in 2 resident bathroom faucets were measured between 127 and 133 degress Fahrenheit, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/25/2025
Plan of Correction
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Staff adjusted the water heater during this visit; LPAs rechecked the hot water temperature but it was too low between 85 and 86 degrees F.
Administrator agreed to take the hot water temparature for 7 days to ensure consistent water temparature and will submit proof to the Department by POC due date.
Type A
Section Cited
CCR
87309(a)(1)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. (1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPAs observed chemicals stored in a garage cabinet where food supplies are being stored. Cabinet was not locked and accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2025
Plan of Correction
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Corrected on site: one staff immediately removed the chemicals and stored in a locked cabinet separate from the food supplies.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/18/2025 04:26 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 06/18/2025 at 01:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PALM VALLEY CARE I
FACILITY NUMBER: 342700735

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(25)
General Food Service Requirements
(b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation], the licensee did not comply with the section cited above. LPAs observed chemicals stored in a garage cabinet where food supplies are being stored, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2025
Plan of Correction
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Corrected on site: staff on duty immediately removed the chemicals and stored them in a locked cabinet.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2025


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 06/18/2025 04:26 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 06/18/2025 at 01:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PALM VALLEY CARE I
FACILITY NUMBER: 342700735

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPAs observed 2 dead cockroaches inside the kitchen freezer and a small live cockroach inside a sliding kitchen drawer. Administrator/licensee is unable to privide proof of pest control services at this time, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/25/2025
Plan of Correction
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Administrator called the pest control for service to be done today.
Administrator agreed to submit the new contract to the Department by POC due date.
Type B
Section Cited
CCR
87465(a)(1)
Incidental Medical and Dental Care Services
(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. Review of resident's medication revealed that 3 medications were not in compliance with the physician's orders. Additionally, one medication was observed to be expired. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2025
Plan of Correction
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Administrator will ensure all resident medications will be in compliance with physician's orders.
Administrator agreed to submit new physician's orders to the Department by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2025


LIC809 (FAS) - (06/04)
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