100404809-1-30-2025-24-AS-MGAA-DDF3RS-20250130172912

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 100404809
Report Date: 01/30/2025
Date Signed: 01/30/2025 05:29:18 PM

Document Has Been Signed on 01/30/2025 05:29 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	PALM VILLAGE RETIREMENT COMMUNITY		FACILITY NUMBER:	100404809
ADMINISTRATOR/ DIRECTOR:	JIM HIGBEE		FACILITY TYPE:	741
ADDRESS:	703 WEST HERBERT AVENUE		TELEPHONE:	(559) 638-6933
CITY:	REEDLEY	STATE: CA	ZIP CODE:	93654
CAPACITY: 262	TOTAL ENROLLED CHILDREN: 0	CENSUS: 164	DATE:	01/30/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:21 AM
MET WITH:	Administrator, Karly Alcantar		TIME VISIT/ INSPECTION COMPLETED:	05:39 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 1/30/2025 Licensing Program Analyst (LPA) M. Garza arrived unannounced for an annual inspection visit. LPA was met by Administrator, Karley Alcantar. LPA introduced self, explained reason for visit and was permitted entry into the facility. LPA completed a health and safety check on residents in care. LPA toured the facility inside and out. Sample resident rooms were observed. There was 5 resident on hospice at the time of the inspection. Pathways and doors were clear and free from obstruction. Common areas were clean, adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors were present and operate on a system. Smoke/carbon monoxide detectors present and operational in independent living. Fire extinguishers last serviced 3/14/2024. Last fire drill on 12/20/2025. Resident rooms observed to have the required furnishings and with adequate lighting. Linen supplies are kept in linen closets. LPA observed sufficient seating under covered patio areas. The following issues were observed during todays visit: Trash can in restrooms not covered. Food in freezer inside snack area not properly stored. Snack area was observed with cabinet full of debris in need of cleaning and a hole needing repair under sink. Beverage servers/ice dispenser in snack area and kitchen galley observed dirty, in need of cleaning. White sputum observed in hallway in need of cleaning/disinfecting. Trash can observed in kitchen galley observed without lid. Food in kitchen refrigerator observed not properly stored and in need of disposal. Kitchen doorway observed with broken tile/laminate in need of repair/replacement. Tools/items posing a danger observed outside off kitchen unlocked and accessible. Trash cans off kitchen observed overflowing and in need of disposal. CONT...

See Moua	TELEPHONE: (559) -580-4596
Mary Garza	TELEPHONE: 559-365-9009
	DATE: 01/30/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

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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Document Has Been Signed on 01/30/2025 05:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 COMMUNITY	FACILITY NUMBER: 100404809
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87555(b)(29)

General Food Service Requirements (b) The following food service requirements shall apply: (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in that lobby cafe and kitchen equipment observed dirty and in use (items not properly cleaned). This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/10/2025
	Plan of Correction
1 2 3 4	Administrator stated a cleaning log has been implemented for equipment needing to be cleaned. Weekly checks should be signed off by supervisors. Training with Kitchen staff will be completed. A copy of training material and in-service sign in sheet will be provided to CCL by POC date as proof of correction.

Type B

Section Cited

CCR

87309(a)

Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in that tools/items posing a danger to residents observed outside, off the kitchen unlocked and accessible. This poses a potential health, safety and or personal rights risk to persons in care.
	POC Due Date: 02/10/2025
	Plan of Correction
1 2 3 4	Administrator stated all staff will be provided training. Training material and in-service sign in sheet will be provided to CCL by POC date as proof of correction. Walk throughs will be completed on a monthly basis as follow up.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

See Moua	TELEPHONE: (559) -580-4596
Mary Garza	TELEPHONE: 559-365-9009
	DATE: 01/30/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/30/2025 05:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 COMMUNITY	FACILITY NUMBER: 100404809
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

HSC

1569.695(a)(1)

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (1) Evacuation procedures, including identification of an assembly point or points that shall be included in the facility sketch. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in that facility sketch does not include assembly point(s). This poses a potential health, safety and or personal rights risk to residents in care.
	POC Due Date: 02/10/2025
	Plan of Correction
1 2 3 4	Administrator stated they will update facility sketch. Copy of updated sketch will be provided to CCL by POC date as proof of correction to place in facility file.

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in that lobby café observed with cabinet full of debris in need of removal and area under sink in need of repair. This poses a potential health, safety and or personal rights risk to persons in care.
	POC Due Date: 02/10/2025
	Plan of Correction
1 2 3 4	Administrator stated trash was removed immediately. Maintenance will repair area under sink. Pictures will be provided to CCL by POC date as proof of correction.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

See Moua	TELEPHONE: (559) -580-4596
Mary Garza	TELEPHONE: 559-365-9009
	DATE: 01/30/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PALM VILLAGE RETIREMENT COMMUNITY	FACILITY NUMBER: 100404809
	VISIT DATE: 01/30/2025

NARRATIVE

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CONT...

LPA requested the following documents to be submitted to CCL by 2/7/25: 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.

Due to facility size and time frames, LPA will return for an annual continuation visit. Exit interview completed with Administrator, Karely. A copy of this report, deficiencies and appeal rights were provided.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary Garza	TELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

LIC809 (FAS) - (06/04)

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