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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003870
Report Date: 06/14/2023
Date Signed: 06/14/2023 12:40:51 PM


Document Has Been Signed on 06/14/2023 12:40 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:PALMERA CARE HOMEFACILITY NUMBER:
347003870
ADMINISTRATOR:COSTEA, ANDREIFACILITY TYPE:
740
ADDRESS:7748 BLACK SAND WAYTELEPHONE:
(916) 677-1078
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY:6CENSUS: 5DATE:
06/14/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Administrator, Andrei Costea TIME COMPLETED:
01:00 PM
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On 06/14/2023, Licensing Program Analyst (LPA) Talwinder Bains conducted an unannounced visit for the purpose of a Plan of Corrections visit (POC's) that were given on a complaint findings delivery visit on 06/06/23. The POC's were due to LPA by 06/07/23 and LPA did not receive the POC's by 06/07/23.

LPA met with administrator, Andrei Costea and explained the purpose of the visit. Administrator stated that they were going through some family emergency and that was the reason facility could not submit required POC documents as required by 06/07/23 however they were ready to submit. Administrator submitted all required POC documents to LPA during today's visit.



No citations were issued during this visit. Exit interview conducted with administrator.
Copy of this report has provided.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
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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