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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604300
Report Date: 09/04/2024
Date Signed: 09/04/2024 01:00:54 PM

Document Has Been Signed on 09/04/2024 01:00 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:PALM VALLEY GROUP HOMES, INC.FACILITY NUMBER:
197604300
ADMINISTRATOR/
DIRECTOR:		EILEEN VASQUEZFACILITY TYPE:
735
ADDRESS:43944 DELGADO CT.TELEPHONE:
(661) 946-3435
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
09/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Eileen VasquezTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On 09/04/2024 at 9:50 a.m. Licensing Program Analyst (LPA) Lorena Casillas arrived at the facility listed above to conduct an unannounced required annual inspection. LPA was greeted by two (2) staff members who granted access and the administrator Eileen Vasquez met LPA shortly after. LPA explained the reason for the visit. Entrance interview conducted.

The facility is Fire Cleared for two (2) ambulatory clients and two (2) non ambulatory clients for a total capacity of four (4) clients. The facility has four (4) bedrooms, three (3) of which are used for clients and one (1) for staff, and two (2) bathrooms.

A tour of the physical plant was conducted with administrator at approximately 10:20 a.m. and the following was observed:

Kitchen: LPA conducted a tour of the kitchen at approximately 10:20 a.m. and observed there to be sufficient supply of two-day perishable and seven-day non-perishable foods, properly stored. Food storage and preparation areas are clean and clear of clutter. LPA observed all knives, sharp objects, locked in a lock box in a kitchen cabinet and inaccessible to clients in care. LPA observed one (1) fire extinguisher to be fully charged with purchased date 04/02/2024.

Common areas: LPA observed the living area and dining area to be clean and clear of clutter. The furniture was in good repair and sits the capacity of the facility. LPA observed a staff test a smoke detector at approximately 10:30 a.m. Detector is interconnected to other detectors located throughout the facility. Carbon monoxide detector was observed to be functioning properly.

Continued on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PALM VALLEY GROUP HOMES, INC.
FACILITY NUMBER: 197604300
VISIT DATE: 09/04/2024
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Bedrooms: LPA inspected four (4) bedrooms, three (3) of which are for client use. One (1) bedroom is shared. LPA observed each client room to be properly furnished with one bed, appropriate nightstand, chair, bedding and with sufficient lighting and storage.

Bathrooms: The facility has 2 bathrooms. One (1) is located in the clients' shared bedroom. LPA took water temperature from one (1) out two (2) bathrooms and temperature was 118.6 degrees F. LPA observed the bathrooms to be clean and properly supplied with hand soap, toilet paper, paper towels and trash bins with lids.



Garage: The garage is attached. LPA observed the washer and dryer are located in the garage accessible to clients and staff. Detergents are kept locked in crates. In the garage LPA also observed emergency food, water and supplies for a disaster. LPA observed the first aid kit with manual up to date.

Surrounding Grounds: Entry and exits were free of obstructions. There is a covered patio with appropriate furniture for client use.

Client/Staff Records: At approximately 11:00 a.m. four (4) out four (4) client records and three (3) staff records were reviewed. Records are kept in a locked file cabinet. Facility utilizes Right Choice and Brea 360 for client's 1:1 care.

Medications: Centrally stored medications are maintained locked in a kitchen cabinet. Medications were observed locked. Centrally Stored Medication Records were reviewed. Medication records are maintained manually. Facility also keeps Medication Administration Records (MAR).

Staff and Client Interviews: At 12:30 pm LPA interviewed staff and clients.

Administrative: Administrator will email LIC500, Resident roster and Bond certificate. Annual fees are current.

No citations issued. Exit interview conducted. A copy of report provided to Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
LIC809 (FAS) - (06/04)
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