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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011405349
Report Date: 10/16/2023
Date Signed: 10/30/2023 02:57:59 PM

Document Has Been Signed on 10/30/2023 02:57 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: DATE:
10/16/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Nathaniel Reed, AdministratorTIME COMPLETED:
02:44 PM
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***This is an amended report*** On 10/30/23 at 2:35 p.m., Licensing Program Analyst (LPA) Greg Clark delivered an amended report to reflect the facility census of 5. On 10/16/23 LPA conducted a case management visit as a follow-up to a substantiated allegation of physical abuse. LPA met with Nathaniel Reed, Administrator and explained the purpose of the visit.

On June 22, 2023, the Department concluded a complaint investigation and substantiated an allegation that staff had physically abused a resident (R2) while in care resulting in bruises and scratches. This complaint was received on February 9, 2023.

On February 2, 2023, staff (S1) was observed by a witness (W1) outside the facility’s front door kicking R2 four times on their back. W1 was in shock and looked away. W1 did not know when the kicking had stopped. W1 did not check R2’s back but observed a bruise on the right eye and dried blood behind R2’s ear. W1 spoke to another resident (R4) who was also being transported from the home to the day program and R4 stated that R2 gets constantly beat with a stick on a daily basis by different staff. When R2 arrived at the day program, staff observed cuts and bruises on R2’s face and ear. Photos of the injuries, incident reports, and trip logs were obtained by the Department which corroborate W1 and day program staff observations regarding R2’s physical appearance.

During the Department’s investigation, interviews conducted with other residents (R4, R5, and R6) revealed that they had witnessed S1 use a yellow stick to hit R2 on multiple occasions. These residents stated that S1 keeps the stick in their room at the facility under S1’s bed. During onsite investigation at the facility, the stick was discovered by the Department under the bed of S1 and confirmed by the administrator that the stick belonged to S1. The Department determined at the conclusion of the complaint investigation that S1 had used the yellow stick to hit R2 on multiple occasions.

***report continues on LIC809C***
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 #2
FACILITY NUMBER: 011405349
VISIT DATE: 10/16/2023
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***report continues from LIC809***

The Licensee was cited for violating California Code of Regulations (CCR) Title 22 § 80072(a)(3) – Personal Rights, which states in part that (a)…each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.”

Based on interviews and records reviewed by the Department, it was determined that R2 was physically abused while in care by S1.

At the time of the complaint investigation visit on June 22, 2023, an immediate civil penalty of $500.00 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code §1548.

The Department has concluded an analysis and has determined that a civil penalty is warranted for physical abuse. The Welfare and Institutions code section § 15610.63 for physical abuse means any of the following: …assault, battery, and physical restraint for punishment.

Today, 10/13/23, the Department will be issuing a civil penalty per Health and Safety Code §1548(f)(1)(A) for a violation that the Department constitutes as physical abuse in the amount of $10,000.00. However, since an immediate civil penalty of $500.00 was previously issued on June 22, 2023, the amount of the civil penalty issued today will be $9,500.00.

A copy of the LIC 421D was given to (facility representative) and originals were signed.

Exit interview conducted. A copy of the report issued. Appeal rights provided. Nathaniel Reed’s signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023
LIC809 (FAS) - (06/04)
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