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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208915
Report Date: 02/18/2022
Date Signed: 02/18/2022 03:40:13 PM


Document Has Been Signed on 02/18/2022 03:40 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: 66DATE:
02/18/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:54 AM
MET WITH:Administrator, Douglas RiceTIME COMPLETED:
11:50 AM
NARRATIVE
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On 2/18/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a Case Management inspection at the above facility. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Douglas Rice.

During the investigation of complaint number 24-AS-20211012140617, the following deficiency was observed:

It was found that on 10/09/2021, Bakersfield Police Department responded to call from facility staff requesting assistance with R1. R1 was exhibiting an aggressive/combative behavior towards staff and other residents. An interview with the Care Coordinator revealed that facility staff “called 911” due to R1’s behavior. R1 was transported to the hospital. Care Coordinator “did not file an incident report” because “there was nothing the police could do”.

Based on interview conducted, a deficiency is being cited in accordance with the California Code of Regulations, Title 22, Division 6, Chapter 8 on the attached 809D

An exit interview was conducted with Administrator. A copy of this report and Appeal Rights will be provided via email, as COVID-19 precautionary measure. Report signed on-site by Facility Representative.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2022
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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Document Has Been Signed on 02/18/2022 03:40 PM - 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: 02/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/18/2022
Section Cited

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87211 Reporting Requirements:(a) Each licensee shall furnish to the licensing agency…(1) A written report… within seven days of the occurrence of…(D) Any incident which threatens the welfare, safety or health of any resident... This requirement was not met as evidenced by:
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Based on interviews, the facility did not submit an incident report for R1 when R1 became aggressive towards staff and other residents resulting in R1 being transported to the hospital, which poses a potential health and safety risk to persons in care.
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Administrator agreed that staff will be trained on the requirements for section 87211 Reporting Requirement Regulations by 03/17/2022 and documentation of training topics and attendance will be submitted to the Fresno CCL office by 03/18/2022.

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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: 02/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2022
LIC809 (FAS) - (06/04)
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