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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002008
Report Date: 08/28/2025
Date Signed: 08/28/2025 12:37:04 PM

Document Has Been Signed on 08/28/2025 12:37 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
ORANGE COUNTY RO, 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: 34DATE:
08/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Administrator Luzviminda BrimbuelaTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On August 28, 2025, Licensing Program Analysts (LPAs) Brandon Lopez and Garlli Tat made an unannounced visit to the facility to conduct the required annual inspection. LPAs were greeted and granted entry into the facility by care giving staff after explaining the purpose for the visit. Administrator (AD) Luzviminda Brimbuela was present and assisted on today's inspection. LPA observed that Luzviminda Brimbuela submitted a renewal application to the Administrator Certificate Bureau on July 1, 2025

The facility is a Adult Resident Facility (ARF) licensed for forty two ambulatory clients. The facility consist of eight client bungalows, a medication room in the front bungalow, a commercial kitchen, a dining room, a multipurpose room, a laundry room, and a garage. LPAs, accompanied by the AD, conducted a tour of the interior portions of the facility. On today's visit, there are thirty four clients in care and five staff present. LPAs inspected all eight client bungalows which consisted of bedrooms, bathroom, and a living room. LPAs observed client bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPAs observed client beds to have clean linens and blankets. LPAs observed additional linens to be stored in a hallway closet in each bungalow. LPA inspected the client bathrooms in each bungalow and observed them to be clean. Bathrooms were equipped with non-skid floor mats. Faucets and toilets were operational. Hot water temperature measured between 108.8 and 117.1 degrees Fahrenheit.

LPAs inspected the commercial kitchen to be kept and inaccessible to clients in care. LPAs observed the commercial kitchen has a two day perishable and a seven day non-perishable food supply on hand. LPA observed kitchen appliances to be clean and operational. LPAs observed the four burner gas stove lights unassisted. CONTINUED ON LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: PALM VILLAGE
FACILITY NUMBER: 306002008
VISIT DATE: 08/28/2025
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LPAs observed kitchen knives and sharps to be stored in the locked kitchen. LPAs observed fire extinguisher to be present in each of the client bungalows and buildings. LPAs observed fire extinguishers to be charged and serviced as of November 4, 2024. LPAs observed that the facility passed their quarterly fire inspection conducted by Bay Alarm Company on August 6, 2025, which consisted of testing smoke detectors and carbon monoxide detectors.

LPAs observed the centrally stored medication to be kept in a locked medicine cart which is located in the front bungalow. LPAs observed the facility has a First Aid Kit stored in the front bungalow and it has all the required components. LPAs observed the facility has a three day emergency food and water supply stored in the pantry located by the dining room. LPAs observed chemicals and toxins to be stored in a locked cabinet in the laundry room. LPAs observed the multipurpose room and the garage to be clear of any obstructions or hazards.

LPAs, accompanied by the AD, conducted a tour of the exterior portion of the facility. The exterior portion was observed to be free of hazards and obstructions. LPAs observed a shaded outdoor seating area with furniture for client use. LPA observed the perimeter gates of the facility to be self latching and can be opened in an evacuation. There are no bodies of water on the premises.

LPAs reviewed eight client files. All the required documentation were present and current in the client files reviewed. LPAs reviewed the clients' medication and medication records. LPAs reviewed clients Personal and Incident Expense monies (P&I). LPAs reviewed five staff files. All staff are background cleared and associated to the facility.

Based on the observations made during today's visit, no deficiencies are being cited per the Title 22 of the California Code of Regulations. An exit interview was conducted with Administrator Luzviminda Brimbuela and a copy of the report was provided.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC809 (FAS) - (06/04)
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