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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002004
Report Date: 07/27/2021
Date Signed: 07/27/2021 12:59:48 PM

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 IIIFACILITY NUMBER:
347002004
ADMINISTRATOR:AURORA MAIGUEFACILITY TYPE:
740
ADDRESS:8725 THETFORD COURTTELEPHONE:
(916) 714-8580
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 6DATE:
07/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Aurora MaigueTIME COMPLETED:
01:00 PM
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On 07/27/21 at 11:45 AM, Licensing Program Analyst (LPA) Christina Valerio arrived at this facility unannounced to conduct an annual inspection visit. LPA Valerio introduced herself, explained the purpose of the visit, and was met by Administrator Aurora Maigue. LPA Valerio was screened for COVID-19 symptoms with temperature prior to being allowed inside the facility.
 
The physical plant was toured inside and outside to ensure the safety of the residents and compliance with Title 22 regulations. LPA also conducted the infection control domain tool. The facility has a LIC 808 mitigation plan uploaded into FAS. LPA observed the facility to have COVID-19 informational signs, social distancing signs, hand washing signs posted throughout the facility. The facility is able to designated and dedicated a Covid-19 bedroom, bathroom, and isolation area if needed.
 
LPA observed the temperature inside the facility was measured at 74 *F, which is within the required range of 68 degrees F and 85 degrees F. The hot water was measured at 113.4 *F and 114.1*F in 2 out of 4 bathrooms, which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). Facility has nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. LPA observed the centrally stored medications area and cleaning supplies to be locked and inaccessible to clients. Resident rooms was sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher is up to date with last check on 01/13/2021. Backyard was observed to have a large area for visiting, exercising, and gardening. All emergency exits were clear from obstructions.
 LPA requested updated copies of documentation: LIC 500 personnel report, LIC 610E Emergency Disaster Plan, and Liability Insurance
 
Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report was left with Administrator Aurora Maigue.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021
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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