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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006071
Report Date: 02/08/2024
Date Signed: 02/08/2024 11:23:43 AM

Document Has Been Signed on 02/08/2024 11:23 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: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: 131DATE:
02/08/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:51 AM
MET WITH:Erin RehbeinTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit in conjunction with complaint visit 22-AS-20240201121336. LPA was greeted and granted entry into the facility and explained the reason for the visit.

During the course of the complaint investigation, LPA interviewed witness and staff. Resident 1 (R1) was admitted at a skilled nursing facility in December 2023 and returned to the facility February 3, 2024. During the resident's absence, resident's belongings were moved to storage and then changed from room 213 to room 212. Facility staff as well as witness indicate there was no notice provided for the room change.




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Based on the observations made from today's visit, deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the Administrator and a copy was provided to Administrator as well as Appeal Rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2024
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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Document Has Been Signed on 02/08/2024 11:23 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 02/08/2024 at 10:52 AM
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: 02/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/22/2024
Section Cited
CCR
87468.2(a)(16)

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 ...residents in privately owned facilities for the elderly shall have all of the following personal rights: To written notice of any room changes at least 30 days in advance unless a room change is agreed to by the resident, required to fill a vacant bed, or necessary due to an emergency. This req is not being met as evidenced by:
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Licensee to submit a statement of understanding of the regulation to LPA by POC due date.
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Based on interviews conducted, Licensee failed to ensure R1 was given a 30 day notice for room change. This poses a potential health and safety risk to residents in care.
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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:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024


LIC809 (FAS) - (06/04)
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