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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100404809
Report Date: 02/23/2023
Date Signed: 02/27/2023 09:54:00 AM


Document Has Been Signed on 02/27/2023 09:54 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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: 68DATE:
02/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:29 PM
MET WITH:Administrator, Karly AlcantarTIME COMPLETED:
06:00 PM
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On 2/23/2023 Licensing Program Analyst (LPA) M. Garza arrived at facility to complete an unannounced infection control/annual visit. LPA met with Administrator, Karly Alcantar and Intermittent CEO, Jim Higbee and explained reason for visit and permitted entry into the facility.

LPA completed a health and safety check on residents in care. Residents observed in common areas and in rooms at time of visit.

Required postings including coughing/sneezing etiquette and hand washing posting observed at hand washing stations and throughout the facility. Furniture in common areas are spaced to promote physical distancing. Bedrooms observed with required furnishings and lighting. Facility telephone was observed working A 30 day supply of PPE and medication observed.. Linens, hygiene and cleaning supplies observed.. Fire Extinguisher last serviced 4/25/22.



LPA requested the following updated forms by 3/2/2023: LIC 308, LIC 309, LIC 500, LIC 610D, and LIC 9020.

No deficiencies cited during todays visit. Exit interview completed with Administrator, Karely and Intermittent CEO, Jim Higbee. A copy of this report was given.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2023
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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