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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005343
Report Date: 02/07/2023
Date Signed: 02/07/2023 02:19:31 PM

Document Has Been Signed on 02/07/2023 02:19 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: 2DATE:
02/07/2023
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Gemma SicatTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a case management visit. LPA met with Facility Staff Gemma Sicat, and explained the purpose of the visit.

On 01/30/23, the Regional Office received an incident report (SIR) for an incident that occurred on 01/25/2023. Resident 1 (R1) was observed by staff to be vomiting continuously. R1 was sent to the emergency room. According to the SIR, the family informed the facility that R1 had a UTI and bowel blockage. R1 returned on 01/28/2023 with a diagnosis of stomach cancer. R1 was also placed on hospice with agency Applied Palliative and Hospice Services, Inc. LPA reviewed facility files. The facility currently has a hospice waiver for 4 residents. The facility and the hospice agency followed R1's care plan as directed by the physician.

No deficiencies were observed during today's visit. An exit interview was held with staff, and copy of the report was given to facility staff.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2023
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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