347003870-9-6-2023-59-AS-TBAS-CVERBR-20230906125312

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347003870
Report Date: 09/06/2023
Date Signed: 09/06/2023 12:53:17 PM

Document Has Been Signed on 09/06/2023 12:53 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 HOME		FACILITY NUMBER:	347003870
ADMINISTRATOR:	COSTEA, ANDREI		FACILITY TYPE:	740
ADDRESS:	7748 BLACK SAND WAY		TELEPHONE:	(916) 677-1078
CITY:	ANTELOPE	STATE: CA	ZIP CODE:	95843
CAPACITY:	6	CENSUS: 5	DATE:	09/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:	Administrator, Andrei Costea		TIME COMPLETED:	01:15 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	Licensing Program Analyst (LPA) Talwinder Bains arrived on 09/06/23 to conduct the annual inspection. LPA met with administrator, Andrei Costea and explained the purpose of today's visit. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (2) and staff files (1). All residents files contained all required paperwork. LPA found out that some required documents were missing in staff's (S1) file during inspection, therefore deficiencies are cited as indicated on LIC809D. LPA and Administrator toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, and common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. All exits were unobstructed. There is a side gate for emergency access. LPA checked the kitchen area for the ability to prepare and store food. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Fire extinguisher is ready for emergency use. Hot water temperature was observed to be 109 degrees F, which is within the regulation range of 105-120 degree. Facility was clean and well organized. All required postings were observed. LPA observed that facility staff left open one of the kitchen drawer with knives and sharp objects open and accessible to residents in care. Furthermore, LPA observed that facility's staff left cabinet open by garage area in laundry room which has disinfectants, cleaning solutions which were accessible to residents in care. Deficiencies are cited on LIC809D per Title 22. Exit interview conducted. Appeal Rights and copy of this report left at facility.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

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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Document Has Been Signed on 09/06/2023 12:53 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PALMERA CARE HOME	FACILITY NUMBER: 347003870
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, LPA found out that facility staff left open one of kitchen drawer with knives and sharp objects and with no lock which was accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/07/2023
	Plan of Correction
1 2 3 4	Licensee will send statement of understanding of this regulation and will train staff as well. Licensee will put a lock on the drawer with knives and sharp objects and will send proof to CCL by POC date, 09/07/23.

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.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/06/2023 12:53 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PALMERA CARE HOME	FACILITY NUMBER: 347003870
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	LPA observed that facility's staff left cabinet open by garage area in laundry room which has disinfectants, cleaning solutions which were accessible to residents and poses potential health and safety risks to residents in care.
	POC Due Date: 09/20/2023
	Plan of Correction
1 2 3 4	The Licensee will send the letter of understanding of this regulation and will train staff regarding this regulation and will send training documents to CCL. POC due date - 09/20/23.

Type B

Section Cited

CCR

87412(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review for staff (S1) file, S1 file missing - LIC501, LIC503, LIC508, LIC9052, TB, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/05/2023
	Plan of Correction
1 2 3 4	Licensee shall complete -LIC501. LIC503, LIC508, LIC9052, TB for staff, S1 and will send proof to CCL by POC date-10/05/23.Additionaly, Licensee will ensure that all required paperwork will be completed for all staff's files per this regulation and will send statement of understanding to CCL by POC date-10/05/23.

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

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

LIC809 (FAS) - (06/04)

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