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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011405349
Report Date: 02/10/2023
Date Signed: 02/10/2023 04:15:28 PM

Document Has Been Signed on 02/10/2023 04:15 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 RESIDENTIAL CARE HOME #2FACILITY NUMBER:
011405349
ADMINISTRATOR:BERTHA REEDFACILITY TYPE:
735
ADDRESS:2212 - EAST 19TH STREETTELEPHONE:
(510) 532-7785
CITY:OAKLANDSTATE: CAZIP CODE:
94606
CAPACITY: 11CENSUS: 7DATE:
02/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:Dana Simpson, Care StaffTIME COMPLETED:
04:30 PM
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On 2/10/23 at 3:55 PM, Licensing Program Analyst (LPA) Greg Clark conducted a Health & Safety inspection as a result of a priority 2 complaint. LPA met with Dana Simpson, Care Staff and explained the purpose of the visit.

LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 115 degrees F in the kitchen sink. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Resident's medications were kept locked in a cabinet in the dining room. Smoke detectors and carbon monoxide detectors were observed. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 4/18/22. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction.

No deficiencies cited during visit. Exit interview conducted and a copy of this report 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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