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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002983
Report Date: 10/26/2022
Date Signed: 10/26/2022 03:03:19 PM

Document Has Been Signed on 10/26/2022 03:03 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:COUNTRY PALMS CARE HOMEFACILITY NUMBER:
397002983
ADMINISTRATOR:TRIPLETT, JOSEPH J.FACILITY TYPE:
740
ADDRESS:2905 BRISTOL AVENUETELEPHONE:
(209) 462-1135
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY: 6CENSUS: 4DATE:
10/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Joe Triplett - AdministratorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced Required 1 year Annual Inspection Visit. LPA met with administrator and explained purpose of visit..

LPA and administrator inspected the physical plant to ensure the health and safety of the residents in care. areas inspected are including but not limited to the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility.

LPA measured the water temperature, temperature measured at 117.0 F degrees which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers were inspected 12/6/2021 and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications, toxins, and sharp knives kept locked and inaccessible to clients. The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility is able to designate and dedicate a COVID-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.

LPA reviewed two (2) Staff and two (2) Resident files that were locked and readily available for review. Staff had current First Aid/CPR certificates.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted with administrator, and a copy of this report was left at the facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2022
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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