<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002008
Report Date: 08/06/2024
Date Signed: 08/07/2024 07:09:11 AM

Document Has Been Signed on 08/07/2024 07:09 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/
DIRECTOR:
LUZVIMINDA BRIMBUELAFACILITY TYPE:
735
ADDRESS:13902 CLINTON ST.TELEPHONE:
(714) 554-8888
CITY:GARDEN GROVESTATE: CAZIP CODE:
92843
CAPACITY: 42CENSUS: 38DATE:
08/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Lucy BrimbuellaTIME VISIT/
INSPECTION COMPLETED:
03:55 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Kimberly Lyman and Samer Haddadin conducted an unannounced visit to conduct the annual required visit. LPAs were greeted and granted entry into the facility and explained the reason for the visit. Facility is licensed for 42 ambulatory clients. Lucy Brimbuella has an Administrator Certificate expiring on 06/02/2025. The facility appears clean and sanitary.
LPAs Lyman and Haddadin along with Administrator Lucy Brimbuella toured the facility at 1:05 PM. LPAs toured the physical plant, checked food service, and reviewed facility documentation. 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. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Client bathrooms were checked. Toilets and water faucets worked properly, and shower was free of mold/mildew. Water temperature measured between 106.5 and 109.7 degrees F in facility bathrooms. Client bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including thermometer, tweezers and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Smoke detectors and fire extinguishers are inspected quarterly by an outside company with the last visit conducted on 05/14/2024. Carbon monoxide detectors tested operational during today's visit. Fire extinguishers are fully charged. LPAs toured the outside grounds and there is ample shaded seating for clients as well as outside activity areas and garden. LPAs observed ample emergency food and water supply. LPAs reviewed the emergency disaster plan as well as infection control plan during the visit. Plans are thorough and complete. Facility provided documentation of last fire drill conducted on 08/05/2024 and drills are conducted quarterly. Facility provides activities in the form of games, exercise and facility social events. At 1:45 PM, LPAs reviewed five client files and fours staff files. Client files contained required documents including admission agreements, physician reports and client appraisals. Staff files reviewed contained required documentation of training and all pertinent paperwork. CONTINUED ON LIC 809C DATED 08/06/2024.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: PALM VILLAGE
FACILITY NUMBER: 306002008
VISIT DATE: 08/06/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
All staff files reviewed contained CPR certification. At 2:00 PM, LPAs reviewed medication storage and administration. Facility uses a medication administration record. Medications are stored in a locked cabinet and are being administered per physician order.



Based on the observations made during today’s visit, NO deficiencies are being cited. This report was discussed with the facility representative and a copy was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2