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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002008
Report Date: 09/11/2023
Date Signed: 09/11/2023 02:34:14 PM

Document Has Been Signed on 09/11/2023 02:34 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, 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: 35DATE:
09/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Carlson Valencia
Luzvminda Brimbuela		TIME COMPLETED:
02:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit to conduct a required annual inspection. LPA was greeted and granted entry by Staff Carlson Valencia. Administrator (AD) Luzvminda Brimbuela was contacted by phone and arrived at 9:15 a.m.

Facility is licensed for 42 ambulatory clients. Facility consists of 8 buildings. One building is for administration, one is an activity room and one is a multipurpose room. The 5 remaining buildings, or bungalows, are for clients. Each bungalow consists of one living room, two or three client rooms and a bathroom. LPA toured the kitchen and dining room and observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. LPA measured the water temperature in each bungalow. Temperature measured 109.0 degrees Fahrenheit to 119.8 degrees Fahrenheit. LPA observed and obtained a picture of at least one client bathroom tub and shower curtain containing mildew; a Deficiency was issued on today's date. All toilets and faucets were found to be operational LPA observed bedrooms had the required furnishings, linens, and blankets. LPA observed first aid kit in facility office and medication room had all the required elements. LPA observed facility menu and calendar in activity room. LPA observed medication room is locked and secured. LPA reviewed six client files, four staff files and conducted staff and client interviews. LPA tested carbon monoxide detector in each bungalow. Last disaster drill was conducted on 8/7/2023, and log was readily available for review. LPA observed fire extinguishers mounted and charged.

Based on the observations made during today’s visit, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2023
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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Document Has Been Signed on 09/11/2023 02:34 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 09/11/2023 at 02:14 PM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PALM VILLAGE
FACILITY NUMBER: 306002008

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as two out of five client bathrroms were observed to have mildew on the shower curtain and in the tub which poses a potential health risk to persons in care.
POC Due Date: 10/11/2023
Plan of Correction
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AD immediately replaced mildew covered curtain with a new one and will conduct an in-service with housekeeping staff to ensure bathtubs and shower curtains are kept mildew free.
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.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2023


LIC809 (FAS) - (06/04)
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