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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002004
Report Date: 01/10/2022
Date Signed: 01/10/2022 03:48:28 PM

Document Has Been Signed on 01/10/2022 03:48 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 IIIFACILITY NUMBER:
347002004
ADMINISTRATOR:AURORA MAIGUEFACILITY TYPE:
740
ADDRESS:8725 THETFORD COURTTELEPHONE:
(916) 714-8580
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 5DATE:
01/10/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Aurora MaigueTIME COMPLETED:
04:05 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) Christina Valerio arrived at this facility unannounced to conduct an annual inspection visit. LPA Valerio was screened for COVID-19 symptoms with temperature prior to being allowed inside the facility. Facility staff confirmed zero residents and/or staff have displayed any signs or symptoms of COVID-19 in the last 10 days. LPA was later met by Administrator Aurora Maigue.
 
The physical plant was toured the facility inside and outside to ensure the safety of the residents and compliance with Title 22 regulations. LPA completed the infection control domain tool and discussed the recent PINs relating to COVID vaccines, boosters, and visitation mandates. LPA observed the facility to have COVID-19 informational signs, social distancing signs, hand washing signs posted throughout the facility. A sign in sheet is located at the front of the facility. The facility is able to designated and dedicated a Covid-19 bedroom and bathroom if needed. Facility common areas, rooms, and bathrooms are cleaned once per shift.
 
LPA observed the temperature inside the facility was measured at 70*F, which is within the required range of 68 degrees F and 85 degrees F. The hot water was measured at 114.3*F and 118*F. Facility has nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. LPA observed the centrally stored medications area and cleaning supplies to be locked and inaccessible to clients. First aid kit was observed and fully stocked with necessary items. Resident rooms was sanitary and had the required furniture and furnishings. Smoke and carbon detectors were in good repair. Fire extinguisher is up to date with last check on 01/13/2021. The facility has made an appointment to have fire extinguishers service prior to expiration date. LPA observed an updated LIC 601E, Administrator certificates, liability insurance, and LIC 500 at the facility. Staff documents are up to date and located in the file.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report was left with Administrator Aurora Maigue and facility staff.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2022
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 1