347002004-12-20-2024-27-AS-AVIA-DC5SX8-20241220131530

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347002004
Report Date: 12/20/2024
Date Signed: 12/20/2024 01:15:42 PM

Document Has Been Signed on 12/20/2024 01:15 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	PALM VALLEY CARE III		FACILITY NUMBER:	347002004
ADMINISTRATOR/ DIRECTOR:	GERWIN SICAT		FACILITY TYPE:	740
ADDRESS:	8725 THETFORD COURT		TELEPHONE:	(916) 714-8580
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	12/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:35 AM
MET WITH:	Winifreda Cochran, Staff on duty (S1)		TIME VISIT/ INSPECTION COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 12/20/2024 at 9:35am, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced to this facility to conduct their required annual visit. LPA initially met with S1 and explained the purpose of the visit. The facility administrator, Gerwin Sicat was informed of the visit and informed is not able to come to the facility today and gave permission to staff on duty to sign this report. Present during this visit were 4 residents in care with 2 staff on duty (S1, S2). LPA evaluated the physical plant with S1 to ensure the health and safety of the residents in care. Areas inspected include but not limited to the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. The facility is a one-story home located in a residential neighborhood. Facility is fire cleared to retain/admit 6 residents with approved hospice waiver for 3 residents. Facility has 6 bedrooms, 6 of which was approved for non-ambulatory. Facility has 3 bathrooms for resident use. 1 of which is located in the master bedroom. LPA observed the facility to be free of odor, clean and in good repair at this time. LPA observed all resident bedrooms to be equipped with the required furniture and sufficient lighting throughout the facility. LPA inspected 3 of 3 bathrooms and were observed to be equipped with slip resistant flooring and overall in good repair at this time. Hot water temperature in 3 resident bathroom was measured between 116 and 119 degrees F. Room temperature was observed at 72 degrees F. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers were observed and were last inspected on 1/23/24. Smoke and carbon monoxide detectors were observed, 1 sample was tested and found operable. LPA observed centrally stored medications, toxins, and sharp objects were kept locked and inaccessible to residents in care. Fireplace was observed to be screened and non-operational at this time. {1 of 2}

Stephen Richardson	TELEPHONE: (916) 263-4700
Arvin Villanueva	TELEPHONE: 916-208-0023
	DATE: 12/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PALM VALLEY CARE III	FACILITY NUMBER: 347002004
	VISIT DATE: 12/20/2024

NARRATIVE

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Outdoor areas were observed to be clean and clear of hazards at this time. No bodies of water was observed at this time. Fence and gates were observed to be in good repair at this time. LPA observed outdoor furniture and outdoor activity area was observed to be spacious for resident use. LPA provided Technical Advisory for licensee to obtain more activity supplies for residents to have options.

Review of 2 sample resident files (R1, R2) which include review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status. No issues were noted.

Medication review of 2 sample residents which includes review of facility's medication log, centrally stored medication record, and physician orders for over-the-counter medications. No issues were noted at this time.

Review of 2 sample staff files (S1, S2) include review of background clearance, First Aid/CPR certificate, Health Screen, Initial and Ongoing Training. Administrator Certificate is current. S2 was found to have fingerprint clearance but not associated to this facility. According to interview and record review of the posted Personnel Report, S2 was employed on 8/1/24. Per interview, S2's transfer request file was submitted to the Department via mail and email. License and/or Administrator did not confirm with the Department if S2 was associated prior to working at this facility.

Facility conducts quarterly disaster drill and last drill was on 8/10/24. Facility does not have infection control plan at this time. LPA reviewed mitigation plan. LPA provided TA for licensee to submit an infection control plan by 12/23/24.

LPA requested a copy of current Liability Insurance Certificate, LIC500 and LIC308 to be submitted by 12/23/24.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were observed during today's visit.

Exit interview was conducted and a copy of the report was provided upon exit.

{2 of 2}

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Arvin Villanueva	TELEPHONE: 916-208-0023
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 12/20/2024 01:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PALM VALLEY CARE III	FACILITY NUMBER: 347002004
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the regualtion cited above. S2 is not associated to this facility but has fingerprint clearance. Per review of the posted Personnel Report dated 8/1/24, S2 was employed on 8/1/24. Per interview, S2's transfer request documents were submitted to the Department via mail and email. However, License and/or Administrator did not confirm with the Department if S2 was associated prior to working at this facility. This which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/23/2024
	Plan of Correction
1 2 3 4	Licensee to resubmit S2's transfer request documents to the Department to be process and to remove S2 from the schedule until S2 is offically associated to this facility.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Stephen Richardson	TELEPHONE: (916) 263-4700
Arvin Villanueva	TELEPHONE: 916-208-0023
	DATE: 12/20/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024

LIC809 (FAS) - (06/04)

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