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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006071
Report Date: 05/24/2022
Date Signed: 05/24/2022 02:06:34 PM

Document Has Been Signed on 05/24/2022 02:06 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:PALMS RETIREMENT CENTERFACILITY NUMBER:
306006071
ADMINISTRATOR:BARRIENTOS, ELEANORFACILITY TYPE:
740
ADDRESS:312 N ROOSEVELT AVETELEPHONE:
(626) 353-4710
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY: 144CENSUS: 103DATE:
05/24/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Katherine TrevinoTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced visit for the purpose of interviewing a Resident (R1) in conjunction with a complaint investigation. LPA Tirre was greeted and granted entry. LPA interviewed Administrator Katherine Trevino and R1. While LPA was conducting visit LPA followed up with Administrator Trevino in regards to Incident Report Department received regarding Resident (R2). Facility reported that on 5/12/22 R2 left facility and refused to sign out that day. Facility noticed the next morning 5/13/22 that R2 had not returned to facility. Per Physicians Report dated 2/27/22, R2 is able to leave facility unassisted. R2 has not returned to facility to date. Administrator is continuing to work with Local Law Enforcement regarding the matter.

An exit interview was conducted with Administrator and a copy of report was left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2022
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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