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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011405349
Report Date: 09/08/2023
Date Signed: 09/08/2023 03:40:49 PM

Document Has Been Signed on 09/08/2023 03:40 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: 5DATE:
09/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Kyana Smith, Care StaffTIME COMPLETED:
03:45 PM
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On 9/08/23 at 1:45 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA spoke with Administrator, Nathaniel Reed on the telephone and explained the purpose of the visit. Administrator gave permission for Care Staff Kyana Smith to sign the report. The facility’s fire clearance was approved for 11 ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen and common areas The facility consists of 5 total bedrooms which 4 bedrooms are occupied by the clients and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 70-degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the kitchen was measured at 119.2-degree Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. The supply of extra hygiene was available for clients. There is a minimum of one-week supply of non-perishables and 2-day perishables food supply.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 3/29/23. Fire drill was last conducted on 7/15/23.

At 1:55 p.m., 5 of 5 clients’ records were reviewed and were complete.

Due to the Administrator being out of town LPA will return at a later date to complete the inspection.

No deficiencies were cited during this inspection. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2023
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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