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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002008
Report Date: 07/28/2022
Date Signed: 07/29/2022 06:53:28 AM

Document Has Been Signed on 07/29/2022 06:53 AM - 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:PALM VILLAGEFACILITY NUMBER:
306002008
ADMINISTRATOR:LUZVIMINDA BRIMBUELAFACILITY TYPE:
735
ADDRESS:13902 CLINTON ST.TELEPHONE:
(714) 554-8888
CITY:GARDEN GROVESTATE: CAZIP CODE:
92843
CAPACITY: 42CENSUS: 39DATE:
07/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:42 AM
MET WITH:Lucy BrimbuelaTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Administrator Lucy Brimbuela and explained the reason for the visit. LPA confirmed Administrator Brimbuela has a current administrator certificate expiring on 06/02/2023. Secretary CFO Michelle Domingo arrived during the visit.

At 8:58 AM, LPA toured the facility with Administrator Brimbuela. Facility has 39 clients in care during today's visit. LPA observed clients relaxing in common outside areas of the facility as well as in the game room. All clients appeared happy and well taken care of. Facility consists of individual bungalows housing 4-6 clients in each one. Facility appears clean and sanitary. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the entrance of the facility. Facility takes resident and staff temperatures daily and documents. Facility has covid precaution postings in each bungalow as well as all required department postings in the visitor check in area. Facility has submitted the mitigation plan and the plan was approved by the department. LPA observed staff and clients wearing masks. LPA observed ample emergency food and water as well as multiple first aid kits throughout the facility. Emergency disaster plan is posted. Fire extinguishers are mounted and charged and smoke detectors/ carbon monoxide detectors are operational. Facility has sanitation stations spread out through the common areas. LPA observed multiple shaded outside visitation areas as well as a vegetable/ herb garden maintained by clients. Facility has an ample supply of PPE and cleaning supplies. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. LPA observed medication cart in the facility. LPA observed the posted activity schedule including games and exercise as well as the activity area. All staff have been vaccinated and most of clients have received the vaccination.

No citations noted during today's visit.

Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2022
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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