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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006071
Report Date: 05/08/2024
Date Signed: 05/08/2024 04:54:22 PM

Document Has Been Signed on 05/08/2024 04:54 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/
DIRECTOR:		BARRIENTOS, ELEANORFACILITY TYPE:
740
ADDRESS:312 N ROOSEVELT AVETELEPHONE:
(626) 353-4710
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY: 144CENSUS: 117DATE:
05/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:32 AM
MET WITH:Assistant Administrator Kathleen TamondongTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
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On 5/8/2024, Licensing Program Analyst’s (LPA’s) Jenifer Tirre, Kimberly Lyman and Edward Kim conducted an unannounced required visit using the CARE Inspection Tool. LPA’s were greeted by staff and granted entry after stating the purpose of the visit. Administrator (Admin) Erin Rehbein was present to assist with the facility inspection on today's date.

The facility is licensed for (144) non-ambulatory residents with approved hospice waiver for ten (10) residents. Currently, there are three (3) Hospice residents present during today’s visit.

At around 9:00am , LPA’s conducted a tour of the physical plant accompanied by Administrator Erin Rebehin, and the following was observed: There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. LPA’s observed one bedroom room 119 to have missing smoke detector. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured between 105.1 to 117.6 degrees F. A comfortable temperature of 76 degrees F. was maintained in the facility.



LPA’s observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. During visit five fire extinguishers were observed as fully charged and mounted. A review of the Medication Records Administration (MAR) was conducted, and LPA’s observed the records are in compliance. A review of staff and resident records were reviewed and observed to be out of compliance.

CONTINUED ON 809C
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: PALMS RETIREMENT CENTER
FACILITY NUMBER: 306006071
VISIT DATE: 05/08/2024
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During the visit, LPA's observed the facility's infection control practices. LPA's observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA's observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA’s observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on 4/4/24. The facility provided documentation from Cal Fire which confirmed operational smoke and carbon monoxide detectors in bedrooms and common areas. The facility has current liability insurance on file effective 8/1/2023- 8/1/2024.

A review of ten residents (R1-R10) service files was revealed to be complete. Ten staff files were reviewed (S1-S10) and ten out of ten personnel files revealed to be incomplete in area training.



Based on the observations made during today's visit, deficiencies are being cited as per the Title 22 Division 6 Chapter 2 of the California Code of Regulations.

An exit interview was conducted, and a copy of this report and appeal rights were provided to Administrator.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024
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Document Has Been Signed on 05/08/2024 04:54 PM - It Cannot Be Edited


Created By: Jenifer Tirre On 05/08/2024 at 04:13 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: PALMS RETIREMENT CENTER
FACILITY NUMBER: 306006071

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412C
Licensee shall maintain in personnel records verification of required staff training and orientation

Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above in ten out of ten staff files are missing hours and specific training topics which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2024
Plan of Correction
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Licensee to provide proof of completed staff records by Plan of correction due date.
Type B
Section Cited
CCR
87303A
The facility shall be clean safe sanitary and in good repair at all times. Maintenance shall include provision of maintenance and procedures for the safety and well being of residents, 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 in one of ten bedrooms was observed missing smoke detector which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2024
Plan of Correction
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Licensee to provide proof of correction of operational smoke detector by plan of correction date. Facility corrected during time of visit.
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:Luz Adams
LICENSING EVALUATOR NAME:Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024


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