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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005343
Report Date: 07/26/2021
Date Signed: 07/26/2021 04:00:58 PM

Document Has Been Signed on 07/26/2021 04:00 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 HOME VIFACILITY NUMBER:
347005343
ADMINISTRATOR:GERWIN SICATFACILITY TYPE:
740
ADDRESS:8644 BANFF VISTA DRIVETELEPHONE:
(916) 612-7209
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 5DATE:
07/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Gerwin SicatTIME COMPLETED:
04:00 PM
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On 07/26/21 at 2:45 PM, Licensing Program Analyst (LPA) Christina Valerio arrived at this facility unannounced to conduct an annual inspection visit. LPA Valerio introduced herself, explained the purpose of the visit, and was met by Administrator Gerwin Sicat. LPA Valerio was screened for COVID-19 symptoms with temperature prior to being allowed inside the facility.

The physical plant was toured inside and outside to ensure the safety of the residents and compliance with Title 22 regulations. LPA also conducted the infection control domain tool. The facility has an approved LIC 808 mitigation plan on file. The facility has one central entry point and has implemented screening and sign in procedures at the front of the home. LPA observed the facility to have COVID-19 Informational and hand washing signs posted at the front door and throughout the facility. The facility has a designated infection control lead and back-up. The facility is able to designated and dedicated a Covid-19 bedroom and bathroom if needed. 

LPA observed the temperature inside the facility was measured at 77 *F, which is within the required range of 68 degrees F and 85 degrees F. The hot water was measured at 110.2*F and 111.6*F in both bathrooms, which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations. 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. Resident rooms was sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguishers was up to date with last check on 03/10/2021.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held with Administrator Gerwin Sicat, and a copy of the report was left at the facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2021
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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