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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320048
Report Date: 11/21/2024
Date Signed: 11/21/2024 01:38:10 PM

Document Has Been Signed on 11/21/2024 01:38 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:PALM TREE HOME INCFACILITY NUMBER:
198320048
ADMINISTRATOR/
DIRECTOR:		ALEXANDER, ELLISFACILITY TYPE:
735
ADDRESS:7323 DALTON AVETELEPHONE:
(323) 833-6837
CITY:LOS ANGELESSTATE: CAZIP CODE:
90047
CAPACITY: 4CENSUS: 4DATE:
11/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:35 AM
MET WITH:Alexander EllisTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
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On 11/21/2024, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced required 1- year visit using the new CARE Inspection Tool. Upon arrival at the facility, LPA Richard met Licensee Ellis Alexander and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved mitigation plan report. There are currently four (4), South Central Los Angeles Regional Center (SCLARC) Adult Residential Care Facility (ARF) consumers in placement. The facility's annual fees are current.


The facility is a single-family home located in a residential neighborhood. Licensee Mr. Alexander and LPA Richard toured the facility which consisted of the following: Living room, kitchen, breakfast nook, dining room, 4 bedrooms, 2 bathrooms, laundry area in the kitchen, locked medication cabinet in the dining room, shaded area, storage room, detached garage, and indoor/outdoor activity areas. The front and back yard landscape is in good condition at the time of the visit.

LPA observed a sanitizing station at the facility entrance; hand sanitizer, thermometer, and PPE supplies are readily available to staff. Sufficient paper, cleaning, and disinfecting supplies were observed

See continued LIC809-C on page 2
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PALM TREE HOME INC
FACILITY NUMBER: 198320048
VISIT DATE: 11/21/2024
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Continued LIC809-C page 2

Documents are posted as mandated. Bedrooms contain the furniture mandated, Bathrooms are clean and operational. Personal accommodations were observed for safety, privacy, comfort, and non-skid surface mats. The kitchen was observed for its ability to prepare and serve food. The food service was reviewed for appropriate quantity and proper storage; there was an ample supply of perishable and nonperishable food. The resident’s medications were reviewed for proper storage, documentation, and system implementation. Medications are locked, and records are current. Common areas were observed for the ability to safely serve the needs of the clients, including cleanliness, and clearness of any potential hazards to the residents.

The first aid kit is fully stocked with manual, smoke, and carbon monoxide detectors were in compliance. The hot water temperature was measured at 113.3F degrees Fahrenheit within the normal limits (105-120F degrees). The fire extinguishers are fully charged, adequate linen supply, the facility telephone is working. The client's bedroom windows have no sliding window lock with thumbscrews, all exit doors were in compliance, the yard was free of debris hazards, and trash cans were covered. Staff was given training on dependent adult and elder abuse reporting. The facility conducted a fire drill on 07/10/24.

There were no deficiencies cited.

Exit interview conducted. A copy of the report was provided to Licensee Ellis Alexander.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC809 (FAS) - (06/04)
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