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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700489
Report Date: 05/12/2022
Date Signed: 05/12/2022 04:45:56 PM


Document Has Been Signed on 05/12/2022 04:45 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:PALMS COURT IFACILITY NUMBER:
342700489
ADMINISTRATOR:OGUNDWIN, ADEOLAFACILITY TYPE:
740
ADDRESS:6821 LINCOLN AVETELEPHONE:
(916) 993-8166
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 2DATE:
05/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Onyekachukwu "Jerry" Aniyie, caregiver TIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with Onyekachukwu "Jerry" Aniyie, caregiver and explained purpose of inspection. LPA and caregiver attempted to contact Administrator several times during inspection but were not able to.

Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and confirmed the facility does not currently have any positive Covid-19 diagnoses. LPA was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: KN95 mask. LPA observed (1) resident in the common area watching television and (1) resident to be in their room. There are currently (0) residents on hospice services.

LPA and caregiver toured the interior and exterior of the facility, including (6) private resident bedrooms, (2) bathrooms, (1) resident shower room, kitchen, common areas, laundry area, and (1) staff room. LPA observed all areas toured to be clean, safe and in good repair and to not pose a health and safety risk or personal rights violation. Inside temperature was observed to be 74* F. Fire extinguisher last serviced 3/10/2022. LPA observed locked toxins in the laundry room, locked medications in a hallway closet and sharps in the pantry where they are regularly locked. LPA observed sufficient 2+day perishable/7+day non-perishable food. First aid kits on site. LPA observed paper towels, soap, sanitizer, and hand-washing posters in the bathrooms. LPA observed sufficient PPE supply and incontinent products. There is (1) outside gate that is unlocked from the inside. LPA observed "mask required" Covid poster outside the front door and hand-washing (20 seconds) in each bathroom. LPA to email additional Covid posters to print and post. Administrator stated Department "See Something, Say Something" poster was moved and has not been re-posted but agreed to. Discussed vaccination status of residents and staff and requirement to be maintaining verification of vaccination status and/or negative test result on file for visitors per PIN 22-07.
cont on 809C..
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: PALMS COURT I
FACILITY NUMBER: 342700489
VISIT DATE: 05/12/2022
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Discussed medication management with Administrator, by phone, and how pre-pouring medication for more than 24 hours is not permitted. Also discussed staff training with medications and accurate documentation of the Medication Administration Record (MAR).

Discussed staff files. Administrator stated they are kept at the facility and agreed to provide training documentation from medication training she has conducted with staff as a licensed medical professional. Discussed how care plans need to be updated at least every 12 months or more frequently, with a change of condition. Administrator stated care plans were last updated on 2/16/2022, not 2/16/2021. Physician's report was updated on 1/17/2022 for resident (R1) who has a diagnosis of Dementia.

Staff present, as well as additional staff and Administrator, are fingerprint cleared and associated to the facility.

Administrator certificate # 6043018740- exp 5/8/2023 and the facility license to be framed and displayed in the office area in the hallway. (Technical Advisory Note issued for License)

LPA requested that an updated copy of LIC500, LIC308 and a copy of the current liability insurance be provided to the Department by 5/19/2022. Administrator to also forward a copy of LIC808 submitted timely, in 2021, for review/approval. The Department's record show that an LIC808 was reviewed/approved for a related facility on/around July 2021.

There are no deficiencies being cited today but a technical advisory note.

Exit interview with caregiver. Copy of report left at facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC809 (FAS) - (06/04)
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