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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002004
Report Date: 01/12/2023
Date Signed: 01/12/2023 02:25:27 PM

Document Has Been Signed on 01/12/2023 02:25 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:
01/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:08 PM
MET WITH:Aurora MaigueTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual inspection.
LPA was met by Administrator Aurora Maigue, and explained the purpose of the visit.

LPA completed the infection control tool. LPA measured the hot water at 114.1*F. The facility room temperature was observed to be 74*F, which is within the required range. The facility was observed to have nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. An emergency supply of food was also observed. Medications, sharps, and toxic supplies were observed to be locked and inaccessible to residents. Fire extinguishers were observed to be in compliance and working condition. The facility common areas were clean, organized, and free from debris. No emergency exits were obstructed. All rooms had required furniture and furnishings. A first aid kit was observed to have all necessary items.

Due to the previous and current storm, the backyard was observed to have the middle fence broken. Administrator is waiting on the insurance to assist in the claim. They are also attempting to talk to the neighbor. No health or safety concerns.

LPA observed updated facility files copies at the facility. LPA requested the following documentation: Liability Insurance, Emergency Disaster Plan, Resident Roster, LIC 500, LIC 308

Per California Code of Regulations (CCR), Title 22, no deficiencies were observed. An exit interview was held with Administrator Aurora, and a copy of the report was given.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2023
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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