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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208915
Report Date: 05/29/2024
Date Signed: 05/30/2024 10:13:16 AM


Document Has Been Signed on 05/30/2024 10:13 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:
05/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:34 PM
MET WITH:Doug Rice, AdministratorTIME COMPLETED:
04:13 PM
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On 05/29/24, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to conduct a case management visit on an incident that occurred. LPA stated the purpose of the visit and was allowed entry into the facility.

On 05/21/24, Resident R1 had a physical altercation with Resident R2 in the memory care unit. The altercation was broke up by staff and Hospice was called for R1's aggressive behavior. R1 was given a PRN for agitation and R2 received first aid treatment. R1 was put on 72 hour chart monitoring for observation. R2 had no complaint of pain. Both families were notified about the incident. There have been no incidents since then.

No deficiencies cited.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
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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