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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604300
Report Date: 10/07/2025
Date Signed: 10/07/2025 01:04:54 PM

Document Has Been Signed on 10/07/2025 01:04 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: 3DATE:
10/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Marlene VasquezTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
NARRATIVE
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On 10/07/2025 at 9:30 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 staff who granted access and called Administrator Eileen Vasquez. Administrator would not be able to meet with LPA and designated staff member Marlene Vasquez to sign the report. 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. Two (2) clients were present, and one (1) client was attending program. There were two (2) staff through vendors RightChoice and Brea360 providing direct care and supervision and one (1) facility staff member present. A tour of the physical plant was conducted with designee at approximately 10:30 a.m. and the following was observed:

Kitchen: LPA conducted a tour of the kitchen at approximately 10:30 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 a purchased date of 03/31/2025.

Continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Lorena Casillas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 10/07/2025 01:04 PM - It Cannot Be Edited


Created By: Lorena Casillas On 10/07/2025 at 10:44 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PALM VALLEY GROUP HOMES, INC.
FACILITY NUMBER: 197604300

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(2)
(e)All individuals subject to a criminal record review pursuant to …shall prior to working, residing or volunteering in a licensed facility: (2)Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in two (2) out of two (2) staff that were not fingerprint cleared which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/08/2025
Plan of Correction
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Administrator over the phone discussed and agreed to removing all vendored staff not cleared or associated to the faciility immediately and provide cleared facility staff to provide care and supervision. Administrator agrees moving forward to only provide staff that is fingerprint cleared and associated to the facility. Citation cleared during visit as cleared staff arrived to replace staff that needed to leave.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Lorena Casillas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2025


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: 10/07/2025
NARRATIVE
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Common areas: LPA observed the living area and dining area to be clean and clear of clutter. The furniture was in good repair and seats the capacity of the facility. LPA observed staff test smoke detector at approximately 10:40 am. Detectors are interconnected to other detectors located throughout the facility. Carbon monoxide detector was observed to be functioning properly.

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. Water temperature measured at 115.2˚ 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 that the washer and dryer are located in the garage accessible to clients and staff. Detergents are kept locked in crates. 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 obstruction. There is a covered patio with appropriate furniture for client use. No bodies of water on the premises.

Client/Staff Records: At approximately 11:30 am three (3) out three (3) client records were reviewed. Upon staff file reviews it was discovered that staff providing one on one (1:1) direct care and supervision were not cleared or associated to the facility. LPA reviewed Guardian background website, and it was determined that RightChoice and Brea360 staff does not have a criminal background clearance, therefore not allowed to provide direct care and supervision to clients. A civil penalty will be issued, please see LIC809-D.

Administrative: Administrator will email LIC500 and Bond certificate. LPA collected client roster and Administrator certificate. Annual fees are current.

Staff and Client Interviews: Throughout facility tour LPA interviewed staff and clients.

Citation issued. Appeals rights discussed and provided. Exit interview conducted. A copy of report provided to designee.
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Lorena Casillas
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC809 (FAS) - (06/04)
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