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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005343
Report Date: 07/16/2024
Date Signed: 07/16/2024 04:04:06 PM

Document Has Been Signed on 07/16/2024 04:04 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 HOME VIFACILITY NUMBER:
347005343
ADMINISTRATOR/
DIRECTOR:		GERWIN SICATFACILITY TYPE:
740
ADDRESS:8644 BANFF VISTA DRIVETELEPHONE:
(916) 612-7209
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 4DATE:
07/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:Gerwin SicatTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On 7/16/24, at 1:40pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived to the facility unannounced to conduct an annual required visit. LPA met with Administrator Gerwin Sicat (ADM) and stated the purpose of the visit. Present during this visit are 3 residents with 2 staff on duty.

LPA and ADM toured the facility inside and out to ensure compliance with Title 22 regulations. LPA observed bedrooms, bathrooms, common areas, kitchen area, dinning area, and exterior areas. Facility is a one-story home located in a quiet residential neighborhood. Facility has 6 private resident bedrooms. At this time, 4 of 6 bedrooms are being occupied. Resident bedrooms were observed to be spacious to accommodate residents' belongings and each bedrooms has an exit to the outside. Two bathrooms were observed and both were equipped with grab bars, commode and non-skid flooring. Solid waste were properly disposed in close lid garbage cans. Medications, toxins, sharps and other dangerous items were observed to be locked and inaccessible to residents. Carbon monoxide/smoke detectors combo were observed, tested and found to be operable. Kitchen area was observed to be clean, sanitary and free of clutter. Technical assistance was provided for licensee to obtain thermometers for the refrigerator and freezers to ensure regulatory temperature is maintained.
Fire extinguishers with last serviced on 3/5/24 and was observed to be in working condition. The facility temperature was comfortable at 80*degrees. Hot water temperature in one bathroom was measured at 107*F. The facility was observed to have an adequate supply of food to meet the requirements of 2 days of perishable foods and 7 days of non-perishables foods. An emergency supply of food was also observed. The facility has a covered patio with outdoor seatings for residents. Technical assistance was provided to replace the right side gate latch with code complaint self-closing latch. Technical assistance was also provided to clear out any tools and store them in their storage shed. Fences and gates on both side of the home were observed to be in good repair. Screens are also maintained and in good repair.

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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2024
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 6
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 HOME VI
FACILITY NUMBER: 347005343
VISIT DATE: 07/16/2024
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LPA conducted record review of 4 staff files and 4 resident files. Technical assistance was provided for licensee to maintain all required documents in the facility. 4 of 4 staff were observed to have current 1st Aid/CPR certificates. Technical assistance was also provided to document their quarterly fire drills. Medication review of 2 of 4 residents was conducted and in compliance.

LPA requested the following documentation: LIC 500, LIC 308, LIC 610D, current Liability Insurance
LPA also reviewed facility's infection control plan and requested licensee to submit to the Department for further review.

Per California Code of Regulations (CCR), Title 22, no deficiencies were observed during today's visit. An exit interview was held, and a copy of the report was provided.



















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

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC809 (FAS) - (06/04)
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