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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700959
Report Date: 01/24/2024
Date Signed: 01/25/2024 02:50:36 PM


Document Has Been Signed on 01/25/2024 02:50 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:PALMS COURT IIFACILITY NUMBER:
312700959
ADMINISTRATOR:OGUNDIWIN, ADEOLAFACILITY TYPE:
740
ADDRESS:1419 CHAMPION OAKS DRTELEPHONE:
(559) 349-3057
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:6CENSUS: 4DATE:
01/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator: Adeola OgundinwinTIME COMPLETED:
01:15 PM
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On 01/24/2024 at 11:30 AM, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA with staff and requested for staff to call and notify administrator of LPA's presence at the facility. Administrator arrived at a later time.

LPA and administrator toured the interior and exterior of the facility to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, residents' bedrooms, bathrooms, kitchen, garage and backyard. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed residents' bathrooms to be clean, sanitary, and in good repair. LPA observed food supplies of non-perishables for a minimum of one (1) week and perishable foods for a minimum of two (2) days. Toxic and cleaning supplies locked and is inaccessible to residents in care. The hot water temperature was measured in the kitchen at 105 degrees Fahrenheit. First aid kit was completed. LPA observed fire detectors and carbon monoxide alarms to be operable. LPA observed medications to be locked and inaccessible to residents in care. LPA observed required Licensing posters posted throughout the facility.

LPA reviewed a total of two (2) resident files. Resident files contain signed admission agreements, physician's reports, appraisals, identification sheets, releases, and resident's rights. Medications are centrally stored and locked. LPA compared medications to those being given for two (2) residents and found no discrepancies. Facility is correctly using the Medication Administration Records (MAR). LPA reviewed a total of two (2) staff record. Staff has training in hospice, postural support, and other various areas of care provision.

During today's visit, no deficiencies are being cited.

Exit interview conducted and report provided.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023
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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