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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601182
Report Date: 03/21/2022
Date Signed: 03/21/2022 03:44:56 PM


Document Has Been Signed on 03/21/2022 03:44 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 GARDEN HOME CAREFACILITY NUMBER:
075601182
ADMINISTRATOR:GUIJO, FLORANTE & VERONICAFACILITY TYPE:
740
ADDRESS:280 ELSIE DRIVETELEPHONE:
(925) 855-0400
CITY:DANVILLESTATE: CAZIP CODE:
94526
CAPACITY:6CENSUS: 0DATE:
03/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Veronica Guijo, AdministratorTIME COMPLETED:
01:15 PM
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On 3/21/2022 at 12:45 PM, Licensing Program Analysts (LPAs) L. Francisco and K. Nguyen conducted a Case Management visit as a result of licensee requested closure of the facility. LPAs met with Licensees Veronica Guijo and Florante Guijo.

On February 18, 2022, Licensee issued a proper 30 day notice to all three residents and sent LPA a copy via email of notice. LPA obtained a copy of R1's placement.

Starting at 12:50 PM, LPAs toured entire facility with Licensee including kitchen, bathrooms, bedrooms, common areas, backyard and garage. LPA confirmed all residents have moved out and facility is currently under construction. Licensee surrendered her facility license during today's visit.

A forfeiture letter will be mailed to licensee at a later time. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2022
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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