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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006071
Report Date: 08/22/2023
Date Signed: 08/22/2023 04:18:19 PM

Document Has Been Signed on 08/22/2023 04:18 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: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: 117DATE:
08/22/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Administrator, Ellen BarrientosTIME COMPLETED:
04:30 PM
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On this day Licensing Program Analyst (LPA) Jenifer Tirre and made an unannounced visit for the purpose of conducting a collateral visit regarding open complaint investigations unrelated to current licensee. LPA met with Administrator Ellen Barrientos and explained reason for the visit:

On this day LPA conducted interviews and gathered pertinent records related to complaint control numbers:

· 22-AS-20200604111128

· 22-AS-20200720143243

Exit interview conducted with Administrator and copy of report was provided to facility.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2023
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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