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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604300
Report Date: 09/13/2022
Date Signed: 09/13/2022 03:10:35 PM

Document Has Been Signed on 09/13/2022 03:10 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:PALM VALLEY GROUP HOMES, INC.FACILITY NUMBER:
197604300
ADMINISTRATOR:JOEL FLETCHERFACILITY TYPE:
735
ADDRESS:43944 DELGADO CT.TELEPHONE:
(661) 946-3435
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 3DATE:
09/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Eileen Vasquez, Administrator TIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Shira Stamps met with Administrator Eileen Vazquez for an unannounced one (1) year Required visit for this facility.

LPA arrived at 1:55 pm and was greeted by caregiver Rufino Collantes. Due to a language barrier, the caregiver did not want to let LPA into the facility. LPA introduced self and told him the purpose of the visit, but the caregiver did not understand and did not want to let LPA into the facility. At 2:00pm, the Administrator arrived and let LPA in. The Administrator spoke to the caregiver and informed him of the Licensing Department and told him he must allow Licensing into the home, and if he was unsure to call her or the Licensee. Two (2) clients were observed in the living room watching TV. The other client just returned from day program. LPA informed the Administrator of the purpose of the visit.

Infection control: LPA reviewed the mitigation plan (approved on 07/14/22) to make sure licensee was following current infection control recommendations. Upon arrival LPA was screened by the Administrator and asked all infection control questions. LPA was signed-in and sanitizer was available.

A tour of the physical plant was conducted with Administrator at 2:24pm. The facility has four (4) bedrooms and two (2) bathrooms currently occupying three (3) clients. One (1) bedroom is designated for staff use only.

Food Inspection
LPA conducted tour at the kitchen around 2:30pm observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas care clean and inaccessible to pests. LPA observed all chemicals, knives and sharp object being locked and inaccessible to clients in care. LPA observed the medication cabinet to also be locked. CONTINUED...
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PALM VALLEY GROUP HOMES, INC.
FACILITY NUMBER: 197604300
VISIT DATE: 09/13/2022
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Physical environment
LPA toured the outside area of the facility at 2:32pm. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. No bodies of water on the premises.

Living and dining
LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 71°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 2:35:pm. There is one (1) fire extinguisher located in the kitchen and was observed to be full and last serviced on 03/25/22.

Resident Rooms
LPA observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each client.

Bathrooms
At 2:30pm LPA observed all bathrooms to have non-skid matts and the appropriated wash your hands signs posted. Hot water was tested and measured within regulation at 115.4 degrees F.

Laundry/Garage
LPA observed the laundry room to be located in the garage. LPA observed all chemicals/hazardous items in a locked storage container. The garage is attached to the facility and stores PPE supplies, a deep freezer, and is used for other storage.

Administrative: LPA collected the resident roster and staffing schedule. Annual fee is current.

An exit interview was conducted and a copy of this report was given to the Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022
LIC809 (FAS) - (06/04)
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