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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208915
Report Date: 09/25/2024
Date Signed: 09/25/2024 12:57:51 PM


Document Has Been Signed on 09/25/2024 12:57 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
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: 60DATE:
09/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:17 PM
MET WITH:Douglas Rice, Administrator TIME COMPLETED:
01:03 PM
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On 09/25/24, Licensing Program Analysts (LPAs) L. Salazar and M. Medina arrived at the facility unannounced to conduct a case management visit based on a self reported incident. LPAs were greeted by Administrator, stated the purpose of the visit and was allowed entry into the facility.

On 09/11/24, facility submitted an incident report for Resident R1. LPAs requested copies of R1's Physician's Report, Needs and Service Plan, Personnel Summary, and Death certificate. All documents were obtained except for the Death certificate, which has been ordered. LPA will review documents and return at a later date if needed.

LPAs toured the facility during the visit to observed the new flooring that was recently completed. No deficiencies cited on today's visit.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024
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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