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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400493
Report Date: 02/10/2023
Date Signed: 02/10/2023 03:23:50 PM

Document Has Been Signed on 02/10/2023 03:23 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:PALM TREE HOMEFACILITY NUMBER:
011400493
ADMINISTRATOR:BIRTHA S. REEDFACILITY TYPE:
735
ADDRESS:2219 EAST 19TH STREETTELEPHONE:
(510) 599-4566
CITY:OAKLANDSTATE: CAZIP CODE:
94606
CAPACITY: 9CENSUS: 0DATE:
02/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Dana Simpson, Care StaffTIME COMPLETED:
03:25 PM
NARRATIVE
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On 2/10/23 at 1:30 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct Infection Control Inspection. LPA met spoke with Administrator, Nathan Reed and explained the purpose of the visit. Care Staff Dana Simpson arrived at 2:00 p.m. and gave LPA access to the facility.

During the Infection Control Inspection, LPA toured facility including but not limited to: front entrance, bathrooms, bedrooms, common areas, kitchen and backyard. Facility has no residents at the current time. No COVID mitigation items were observed. Only eggs and milk were observed in the refrigerator.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted and a copy of this report and appeal rights provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2023
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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Document Has Been Signed on 02/10/2023 03:23 PM - It Cannot Be Edited


Created By: Gregory Clark On 02/10/2023 at 02:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PALM TREE HOME
FACILITY NUMBER: 011400493

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087 Buildings and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation the licensee did not meet the above requirement as evidenced by: the facility was not clean, safe or sanitary. Cleaning supplies and construction materials were left unlocked which poses an immediate risk to persons in care.
POC Due Date: 02/13/2023
Plan of Correction
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Licensee will have the facility in regulatory compliance by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Gregory Clark
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023


LIC809 (FAS) - (06/04)
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