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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208915
Report Date: 03/19/2021
Date Signed: 03/19/2021 01:47:24 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:PALMS AT SAN LAUREN, THEFACILITY NUMBER:
157208915
ADMINISTRATOR:RICE, DOUGLASFACILITY TYPE:
740
ADDRESS:5300 HAGEMAN RDTELEPHONE:
(661) 218-8333
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93308
CAPACITY:68CENSUS: 39DATE:
03/19/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:16 PM
MET WITH:Administrator, Douglas RiceTIME COMPLETED:
01:46 PM
NARRATIVE
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On 3/19/2021, Licensing Program Analyst (LPA) A. Walton contacted Administrator, Douglas Rice to conduct a Case Management-Deficiencies visit via telephone due to COVID-19 and precautionary measures. LPA explained the purpose of the call with Administrator.

During the course of a complaint investigation, it was found that on 10/21/2020, Administrator failed to protect the personal rights of clients in care to receive safe and healthful accommodations and engaged in conduct inimical to the health, welfare, and safety of clients in care, in that facility staff S1 failed to wear face coverings while providing care and supervision to clients in care, in violation of official government orders requiring the wearing of face coverings while working under specified conditions.

Based on observation of a video recording, a deficiency is being cited in accordance with the California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87468.1.

An exit interview was conducted and a Plan of Correction was reviewed and developed with Administrator. A copy of this report and Appeal Rights were provided to Administrator, via email and an electronic read receipt confirms receiving these documents. Facility Representative signature on file.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2021
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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PALMS AT SAN LAUREN, THE
FACILITY NUMBER: 157208915
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/22/2021
Section Cited

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87468.1 Personal Rights of Residents in All Facilities (a)(2): Residents... shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment
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This requirement was not met as evidenced by: Based on observation of a video recording, Licensee did not ensure residents were accorded safe, healthful, and comfortable accomodations when S1 removed S1's face mask while providing care to R1 on 10/21/2020.
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Administrator stated that staff will be trainined on PPE requirements. Documentation of training topics and attendance will be submitted to the Fresno CCL office by 4/19/2021.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2021
LIC809 (FAS) - (06/04)
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