486804369-12-5-2025-21-AS-MCUA-DP3U79-20251205141934

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804369
Report Date: 12/05/2025
Date Signed: 12/05/2025 02:20:51 PM

Document Has Been Signed on 12/05/2025 02:20 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	CASA PALMA CARE HOME		FACILITY NUMBER:	486804369
ADMINISTRATOR/ DIRECTOR:	PALMA, HANZ		FACILITY TYPE:	740
ADDRESS:	2355 BURGUNDY WAY		TELEPHONE:	(707) 386-5073
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY: 6		CENSUS: 0	DATE:	12/05/2025
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:34 AM
MET WITH:	Hanz Palma (Applicant)		TIME VISIT/ INSPECTION COMPLETED:	01:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Cuadra arrived announced to conduct a pre-licensing inspection and was greeted by Applicant, Hanz Palma and Amy Villasan. Facility currently does not have residents in care. Once obtained, Applicant will submit proof of required liability insurance. The facility has submitted a dementia care plan. Hospice waiver for two residents. The facility consists of a single story residence with a total of five bedrooms, One shared bedroom (room #2 & # 6), two full bathrooms, staff room, laundry area located in the hallway, kitchen, dining room, living room as common areas an outside sitting & garden area available for resident use. Lock storage shed located at the back of the facility. Applicant lives on the premises in a detached unit located in the back of the facility. LPA explained that every individual who could reside at this detached unit needs to be fingerprinted prior to live, work or volunteer at the home. The facility received a fire clearance approval on 9/10/2025 by the City of Fairfield Fire Department for total capacity of six (6) residents which four (4) may be non-ambulatory residents in rooms 2 (shared), 4 and 5 and two (2) are ambulatory residents in rooms 1 and 3, which none may be bedridden nor is approved of delayed egress devices. Administrator certificate for administrator Hanz Palma #6079330740 expires on 9/24/2027. Contact information reviewed. LPA observed all required postings including the CCL Complaint Poster, Long Term Care Ombudsman Poster, Resident's Rights, and the rights to Resident and Family Councils. Continues on LIC809C...

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/05/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CASA PALMA CARE HOME	FACILITY NUMBER: 486804369
	VISIT DATE: 12/05/2025

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Continued from LIC809...

At approximately 9:45am LPA/Applicant toured the building and grounds. The facility was found to be consistent with facility sketch, and at a comfortable temperature. Indoor and outdoor passageways are free of obstructions and is enough to permit residents with a diagnosis of dementia wander freely and safely. Window screens are clean and in good repair. All resident rooms are furnished per regulation with bed, lamp, bedside table, dressers and chairs. Garage houses gardening tools storage, incontinence care supplies and emergency supply of water. Cleaning supplies will be stored in a cabinet located in the garage, and locked cabinets located under kitchen sink and laundry area. Sufficient supply of linens and hygiene products observed. Kitchen cabinet has locks installed for knives to be inaccessible to residents in care. Locked centralized medication cabinet is located in the kitchen including first aid kit. First aid kit present with all required items. Garbage cans have tight fitting covers, there are sufficient amount of dishes, utensils, cooking pots, etc. Office has locked door and cabinet with a lock that will be used for confidential file storage of personnel and residents records.

Back yard is connecting to shared bedroom #2 & 6, bedroom # 4 and 5 allowing access to the backyard, and they have auditory alarms installed at the doors that were tested and operational during the visit. Emergency lighting and flashlights available. Each room has an alert pendant that it was found operational. Water temperatures read at: 105.1 and 105.6 degrees F which is within 105-120 F degrees regulation. All bathrooms have grab bars and skid mats available. Smoke and carbon monoxide detectors present and functioning. Two fire extinguishers serviced on September 2025. Night lights in hallway are present. Activity calendar and supplies as well as sample of menu was observed. The Applicant agreed that they need to include the use of surveillance cameras in common areas to their admission agreement to make residents and their responsible parties aware of their use without audio.

Applicant has satisfied all requirements in accordance with Title 22 Regulations including Component III. LPA will notify Application Unit Pre-licensing inspection is complete to proceed with the process of license. Pre-Licensing is now complete. Exit interview conducted with Applicants and a copy of this report was given.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/05/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2025

LIC809 (FAS) - (06/04)

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