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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700735
Report Date: 06/23/2023
Date Signed: 06/23/2023 02:58:08 PM


Document Has Been Signed on 06/23/2023 02:58 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:PALM VALLEY CARE IFACILITY NUMBER:
342700735
ADMINISTRATOR:ANGELITA DAYOANFACILITY TYPE:
740
ADDRESS:8700 MILO COURTTELEPHONE:
(916) 686-2128
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 6DATE:
06/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:41 PM
MET WITH:Merceditas Galito TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct an annual required visit. LPA met with facility staff, and explained the purpose of the visit. LPA observed 2 staff and 1 personal caregiver. LPA was later met by licensee/Administrator Angelita Dayoan.

LPA toured the facility to ensure compliance with Title 22 regulations. LPA observed 7 bedrooms, one of which is a staff bedroom. Bedrooms were observed to have the necessary furniture and furnishings and appeared to be clean and organized. Three bathrooms were observed to have skid mats, handle bars, soap, sanitizer, hand paper towels, and lidded trash cans. The temperature in the home was 74* degrees F and the hot water was measured at 110.2*F. Common areas were observed to be clean, organized, and free debris. All emergency exits were clear. Fire extinguishers were in working condition with an annual inspection of 05/15/2023. Carbon dioxide and smoke detectors were observed. A first aid kit was observed to have all necessary materials in case of an emergency. The facility had a food supply to meet the requirements of 7 day of non-perishables and 2 days of perishables. A emergency supply of food and water was also observed. Cleaning supplies, medications, and sharps were locked away and inaccessible to residents in care. The backyard was observed. The backyard has a large seating area, a garden area, BBQ smoker, and a gated pool. No health or safety concerns were notes. LPA reviewed 6 residents files and 3 staff files. All files were up to date with no noted concerns. During the tour, LPA spoke to residents and staff. LPA observed staff, residents, and family members celebrating a resident's birthday. Throughout the visit, other residents were watching television, taking a nap, and being assisted with ADLs.

LPA obtained Liability Insurance Information and requested the following be sent to the RO: LIC 500, LIC 308, and LIC 610

Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed. An exit interview was held, and a copy of the report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2023
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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