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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208915
Report Date: 03/10/2022
Date Signed: 03/10/2022 04:19:05 PM


Document Has Been Signed on 03/10/2022 04:19 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: 64DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:09 PM
MET WITH:Administrator, Douglas RiceTIME COMPLETED:
02:40 PM
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On 03/10/2022, Licensing Program Analyst (LPA) Walton arrived unannounced at the above location to conduct an Infection Control Inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Douglas Rice.

Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Bathrooms have trash cans with lid. Hand washing posters were observed by the bathroom sink. Residents at the above facility have private apartments.

LPAs checked residents’ locked medications and observed a 30-day supply. Food supply was checked and there appeared to be an adequate supply. Cleaning and PPE supplies were checked. Staff records were reviewed for good health and infection control training. Facility staff was observed with mask on. Residents wear masks when away from the community. Resident’s files have updated emergency contact information.

LPA is requesting the following documents be submitted to the Fresno CCL office by 03/24/2022: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan LIC 610E Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020A, Surety Bond.

No deficiencies issued.

Exit interview conducted. A copy of this report will be provided via email due to COVID-19 precautionary measures. 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: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022
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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