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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100404809
Report Date: 02/10/2022
Date Signed: 02/10/2022 01:40:34 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:PALM VILLAGE RETIREMENT COMMUNITYFACILITY NUMBER:
100404809
ADMINISTRATOR:JIM HIGBEEFACILITY TYPE:
741
ADDRESS:703 WEST HERBERT AVENUETELEPHONE:
(559) 638-6933
CITY:REEDLEYSTATE: CAZIP CODE:
93654
CAPACITY:262CENSUS: 168DATE:
02/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Jim Higbee
Karely Alcantar
TIME COMPLETED:
01:04 PM
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On 2/010/22, Licensing Program Analyst, M. Medina arrived at the facility unannounced to conduct the required Infection Control Inspection. LPA was greeted by screener, COVID screening was completed prior to LPA's entry. LPA observed a central entry point with a supply of hand sanitizer located upon entry. A sign in policy that includes documented routine symptom screening for visitors is currently being implemented to follow current visitation guidelines. All staff utilize a separate entrance with COVID infection protocols prior to starting shift. Mitigation plan was received. COVID-19 procedures described in the plan include required postings, symptoms screenings (for staff, persons in care and visitors), testing, quarantine/isolation cohorts, infection control plan to include donning and doffing of Personal Protective Equipment. Staffing and sick leave plans are in place for emergency staffing and/or PPE shortages.

LPA toured the facility inside and out. Required postings of signs to include hand washing, coughing etiquette and physical distancing were observed throughout the facility. Staff were all observed wearing face coverings. Facility has designated visitation areas. LPAs observed a 30 day supply of PPE and resident medications. Several residents rooms in Assisted Living, Independent Living and Memory Care toured and observed to have adequate soap and paper products available.

LPA received copies of Administrator Certificate, LIC 500, LIC 610, and LIC 9020 during inspection visit.

Through LPA's observation of documentation and interview with Administrator, the required infection control practices are found to be in compliance. No deficiencies were observed. Exit interview was conducted and report signed. Administrator was informed that as a COVID-19 precautionary measure, this report will be emailed.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
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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