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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003870
Report Date: 07/12/2023
Date Signed: 07/12/2023 10:55:48 AM


Document Has Been Signed on 07/12/2023 10:55 AM - 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:
07/12/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:13 AM
MET WITH:Andrei Costea TIME COMPLETED:
11:15 AM
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On 07/12/23, around 10:13 AM, Licensing Program Analyst (LPA), Talwinder Bains, Regional Manager, Alycia Berryman and Licensing Program Manager, Laura Munoz were present for a Non-compliance Conference with Licensee Anderi Costea which was held in-person in the office.

ยท A complaint was submitted to the Department on 02/27/23, alleging financial abuse by staff (S1) to resident (R1). On 06/06/23, the department delivered the findings for complaint as Substantiated and immediate exclusion for S1. The department delivered findings for the substantiated complaint that Staff (S1) financially abuse R1. Department served the immediate exclusion for S1. Two citations (type-A) were issued under title 22, regulation, 87217 - safeguards for Resident Cash, Personal Property, and Valuables and 87355 Criminal Record Clearance. Furthermore, Civil penalty of $500.00 been issued to facility due to unassociated staff (S1) working at the facility.

The licensee shall submit the following:
  • Licensee shall submit a statement to CCL understanding that S1 will not be allowed and/or present in the facility
  • Licensee shall submit a plan on how resident's cash, property and valuables will be safeguarded.
  • Licensee shall secure additional staffing for both licensed facilities. Licensee shall submit an LIC500 with additional staffing. Licensee shall ensure additional staff are fingerprinted and associated to the facility.
  • Licensee shall submit a statement to CCL understanding Title 22 Reporting Requirements

Compliance plan documents shall be submitted to CCL by: July 17, 2023 COB
talwinder.bains@dss.ca.gov

The licensee agreed with the drafted non-compliance plan as outlined in LIC 9111.

No citations were issued today. An exit interview was conducted, and a copy of this report was provided to the licensee.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2023
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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