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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 04:50:03 PM


Document Has Been Signed on 05/12/2022 04:50 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
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:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Onyekachukwu "Jerry" Aniyie, caregiver TIME COMPLETED:
04:50 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection, while also conducting an annual inspection, to follow up on a death report received on 4/4/2022.. LPA met with Onyekachukwu "Jerry" Aniyie, caregiver and explained purpose of inspection. LPA and caregiver attempted to contact Administrator several times during inspection but due to an emergency, Administrator was not able to return LPA's call until approximately 3:30 pm.

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 discussed death report (LIC624A) received by the Department on 4/4/22 for resident (R1) who passed and was not receiving hospice services. Report indicates that resident was discharged from hospice on 10/29/2021. Administrator stated that resident's family was going to put resident back on hospice but she passed. Administrator stated that resident was receiving home health services, including physical therapy prior to passing. Administrator agreed to reach out to resident's family and provide the Department with an official death certificate once available and/or documentation showing resident was approved to go back on hospice. Documentation to be submitted to the Department by 5/26/2022.

There are no deficiencies being cited on this report.

Exit interview with caregiver. Administrator authorized caregiver to sign today's report.
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)
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