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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208915
Report Date: 06/08/2023
Date Signed: 06/08/2023 11:35:59 AM


Document Has Been Signed on 06/08/2023 11:35 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
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: 65DATE:
06/08/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Administrator Douglas RiceTIME COMPLETED:
11:45 AM
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Licensing Program Analysts (LPA)'s Shawna Doucette and Darius Williams arrived at the facility unannounced to commence and complaint investigation and deliver findings for Complaint AS-20230321111428 and Complaint 24-AS-20230330093440. LPA's met with Administrator Douglas Rice.

During the course of the investigation LPA's observed the following deficiencies. LPA requested records for the signal system for 3/15/23 to 03/31/23. Administrator stated he was unable to provide those records due to the system recording over every 2 days. During the course of the investigation after interviewing witnesses it was found the records are permanent and do not erase.

LPA was unable to locate an incident report for R1 regarding incident in complaint 24-AS-20230330093440. LPA requested copy of the incident report for R1 while at the facility. Resident Care Coordinator Emily Conrad and Administrator Douglas Rice were unable to provide a copy of this incident report. Resident Care Coordinator stated facility does not have an incident report for this incident.

Refer to 809D for cited deficiencies.

An exit interview was conducted with Administrator Douglas Rice and a copy of this report was provided with plans of corrections and appeal rights.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 06/08/2023 11:35 AM - 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
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: 06/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/20/2023
Section Cited
CCR
87405(a)(3)

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87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.
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Plan of Correction POC Administrator agrees to submit a written plan on how this regulation with be met in the future by POC due date of 06/20/23.
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(3) Ability to maintain or supervise the maintenance of financial and other records. This requirement was not met as evidenced by: Administrator did not provide requested records for the dates of 3/15/23 to 03/31/23 for the signal system at the facilty which poses a potential health, safety and/or personal rights risk to residents in care.
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Type B
06/20/2023
Section Cited
CCR87211(a)(1)

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through
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Plan of Correction POC Licensee agrees to submit an understanding of this regulation and a plan in writing on how this regulation will be met by POC due date of 6/20/23.
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(D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement was not met as evidenced by: Facility did not report emergency services responding for R1 which poses a potential health, safety and/or personal rights risk for residents in care.
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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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2023
LIC809 (FAS) - (06/04)
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