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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209060
Report Date: 06/13/2024
Date Signed: 06/13/2024 12:41:01 PM

Document Has Been Signed on 06/13/2024 12:41 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 GARDEN RETIREMENT HOME & DEMENTIA CAREFACILITY NUMBER:
107209060
ADMINISTRATOR/
DIRECTOR:		KOPACZ, CAMALAH S.FACILITY TYPE:
740
ADDRESS:8891 E. HERNDON AVE.TELEPHONE:
(559) 324-1733
CITY:CLOVISSTATE: CAZIP CODE:
93619
CAPACITY: 6CENSUS: 4DATE:
06/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Administrator Camalah CopaczTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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On 06/13/2024, Licensing Program Analyst (LPA) V. Gorban arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility. LPA toured the facility with facility staff Charmen Francis. Administrator (AD) Camalah Copacz, Licence number 6044267740 and expiration date 05/11/2025 was notified of Licensing visit over the phone was able to attend the visit.

The facility was observed to be at a comfortable temperature, of 74 degrees F. Facility is free of debris, in good repair, and no passageway obstructions or fire hazards were observed. Common areas were properly furnished and well-lit throughout. LPA observed some residents in common area during breakfast watching television, others in their room still in bed. Department phone number and infection prevention information signs were posted thought the facility.

Inspecting kitchen LPA observed the required 7-day supply of non-perishable food and 2- day supply of fresh perishables to be properly stored. An emergency disaster supply was observed.

A fire extinguisher was observed with a service date of 05/16/2024. All six private residents’ bedrooms were observed to be at comfortable temperatures. The bathroom’s water temperature was tested and recorded reading of 111 degrees F.

Medications observed to be locked in a cabinet in the common area. LPA reviewed medication records appears to be administered properly. Cleaning supplies were observed to be in a locked cabinet in the storage it the laundry room. An outdoor seating area was observed operational for residents in care.

Report continues on attached LIC809-C

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2024
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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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 GARDEN RETIREMENT HOME & DEMENTIA CARE
FACILITY NUMBER: 107209060
VISIT DATE: 06/13/2024
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Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below:

Residential Care Facility for the Elderly (RCFE):


· LIC 308 Designation of Facility Responsibility
· -as applicable: LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly
· LIC 9020 Register of Facility Clients/Residents
· Copy of current Liability Insurance
· Copy of current Administrator Certificate
· Alternate contact information including name, telephone number, & email address.

Please submit the above forms/information to Fresno CCL by: 06/20/2024

As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed.


LPA reviewed staff and residents’ files. No deficiencies were observed and cited during this visit. Advisory notes were created for Administrator to follow up by 6/20/24.


Exit interview conducted. A report was signed, and a copy of this report was provided for facility records.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC809 (FAS) - (06/04)
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