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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100404809
Report Date: 01/22/2024
Date Signed: 01/22/2024 10:08:44 AM


Document Has Been Signed on 01/22/2024 10:08 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: 177DATE:
01/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:42 AM
MET WITH:Chief Executive Officer, Jim HigbeeTIME COMPLETED:
10:14 AM
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On 1/22/24 Licensing Program Analyst (LPA) M. Garza arrived unannounced for an annual inspection visit. LPA was met by Receptionist, Janet Tena. LPA introduced self, explained reason for visit and was permitted entry into the facility. Chief Executive Officer, Jim Higbee and Administrator, Karley Alcantar were contacted and arrived a short time later.

LPA was informed that the facility has positive COVID. LPA will return at a later date for an annual continuation.

LPA requested the following documents to be submitted to CCL by 2/2/24: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-E), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file.

No deficiencies were cited during the inspection. Exit interview completed with Chief Executive Officer, 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: 01/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2024
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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