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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002004
Report Date: 01/03/2024
Date Signed: 01/03/2024 04:37:56 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/03/2024 04:37 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 IIIFACILITY NUMBER:
347002004
ADMINISTRATOR:AURORA MAIGUEFACILITY TYPE:
740
ADDRESS:8725 THETFORD COURTTELEPHONE:
(916) 714-8580
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
01/03/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Grant Depositar, Assistant AdministratorTIME COMPLETED:
04:30 PM
NARRATIVE
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On 1/3/2024 at 10:15am, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility to conduct an unannounced Case Management-Annual continuation visit to continue with the Annual visit initiated on 12/27/2023. LPA initially met with staff on duty and explained the purpose of the visit. The facility assistant administrator, Grant Depositar was informed of the visit and arrived shortly after. Present during this visit were 6 residents in care with 2 staff on duty.

During this inspection, LPA conducted an audit of facility files, 6 resident files, and 8 staff files for regulatory compliance. LPA completed resident interviews and 2 staff interviews. 6 out of 6 resident files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required. 8 out of 8 staff files reviewed contained all required contents including health screening, TB results, current first aid/CPR, and initial and ongoing required trainings. Facility’s liability insurance is current per regulatory requirements. The facility is current on annual license fees. LPA reviewed facility’s disaster plan to ensure regulatory compliance. Facility conducts quarterly fire drills.

Medication storage area was observed to be locked and inaccessible to residents in care. Medications were reviewed for accuracy. First aid kit was observed to have adequate supplies and accessible to staff. The facility maintains for each resident Centrally Stored Medication, Destruction Record and PRN Log. LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed facility to have sufficient equipment and supplies to meet activity program needs of residents in care.

Note: LPA Villanueva was unable to open the CARE Tools during this visit.

Per California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 9099-D).

{Con't to LIC809-C}

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2024
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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Document Has Been Signed on 01/03/2024 04:37 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 01/03/2024 at 03:04 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 III
FACILITY NUMBER: 347002004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/10/2024
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care: (a)(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
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If medication administration record is being utilized, licensee will ensure staff signature are mark on the medication record ensuring medications were given to the correct residents and in the correct time.
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Based on interview and observation, the licensee did not ensure 6 of 6 residents' medication administration record that staff signatures were absent from 1/2/24 to morning of 1/3/24 which poses/posed a potential health, safety or personal rights risk to persons in care.
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Licensee to submit a statement of understanding of the CCR 87465(4) to the Department by the POC due date.
Type B
01/10/2024
Section Cited
CCR87411(f)

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(f) All personnel...shall be in good health, and...shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.
This requirement is not met as evidenced by:
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Licensee will ensure all personnel have a valid health screen report not more that 6 months prior to or 7 days after employing staff.

Licensee to submit recent health screen report of the staff to the Department by the POC due date.
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Based on record review and interview, licensee did not ensure that 1 of the 8 staff files reviewed had a valid health screen report. This posed a potential health and safety risk to resident in care.
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Licensee to submit a statement of understanding of the CCR 87411(f) to the Department by the 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.
SUPERVISOR'S NAME:Stephen Richardson
LICENSING EVALUATOR NAME:Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2024


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 III
FACILITY NUMBER: 347002004
VISIT DATE: 01/03/2024
NARRATIVE
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{Con't from LIC809}

The following deficiencies were observed during today’s inspection:

· During medication review, LPA observed that the medication administration record for all 6 residents have missing staff signature on the following dates: 1/2/2024 (all day) and 1/3/2024 (morning).

· During staff file review, LPA observed that 1 staff did not have a valid health screen report (LIC503). Staff was hired in 2021 and the LIC 503 on file is from 2017.

· During resident file review, LPA observed that 1 out of 6 resident in care did not have a TB test done on record prior to admittance to this facility. Assistant administrator, Grant, attempted to obtain the record from previous residence but per Grant, record of TB test was not obtained. However, a recent record of TB test was done and the result was negative.

An exit interview was held with Grant Depositar, and a copy of this report and appeal rights were provided to the facility.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. *

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

DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/03/2024 04:37 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 01/03/2024 at 04:09 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 III
FACILITY NUMBER: 347002004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/10/2024
Section Cited
CCR
87458(b)(1)

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87458(b)(1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious diseases or other medical conditions which would preclude care of the person by the facility.
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Licensee will ensure that TB test is done prior to admitting resident to this facility.

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This requirement is not met as evidenced by:
Based on record review and interview, licensee did not ensure 1 of 6 resident had a TB test done prior to acceptance to this facility. This posed a potential health and safety risk to resident in care.
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Licensee will submit a statement of understanding of the CCR 87458 to the Department by the 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.
SUPERVISOR'S NAME:Stephen Richardson
LICENSING EVALUATOR NAME:Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2024


LIC809 (FAS) - (06/04)
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