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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005343
Report Date: 07/14/2025
Date Signed: 07/14/2025 04:14:15 PM

Document Has Been Signed on 07/14/2025 04:14 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 HOME VIFACILITY NUMBER:
347005343
ADMINISTRATOR/
DIRECTOR:		GERWIN SICATFACILITY TYPE:
740
ADDRESS:8644 BANFF VISTA DRIVETELEPHONE:
(916) 612-7209
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 4DATE:
07/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Gerwin SicatTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On 7/14/2025, Licensing Program Analyst, Arvin Villanueva (LPA) arrived unannounced at this facility to conduct the annual inspection visit. LPA met with Licensee/Administrator Gerwin Sicat (S1), and stated the purpose of the visit.

Overview: Facility is a one-story home located in a residential neighborhood. Facility is licensed to serve up to 6 elderly residents who may be ambulatory and/or non-ambulatory. Facility has an approved hospice waiver for up to 4 residents. Currently, there are no residents in care receiving hospice care. Facility does not handle resident cash resources.

Initial Observation: Upon arrival LPA observed 2 staff on duty (S1 and S2) with 4 resident in care (R1, R2, R3, R4). Per interview with S2, residents are in their bedroom taking a nap. LPA observed required posters and facility license at the entrance. Room temperature was at 80 degrees Fahrenheit upon arrival.

Physical Inspection:
Areas inspected include, but not limited to, the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. LPA inspected 4 of 6 resident bedrooms and were observed to be equipped with the required furniture and sufficient lighting throughout. 2 of 6 bedrooms are currently unoccupied. LPA measured the hot water temperature in the 1 of 2 bathrooms to be at 107 degrees Fahrenheit. In one of the bathroom, LPA observed the under the sink cabinet to be in disrepair as evidenced of the lock not functioning properly. Advisory was provided to licensee to make necessary repair.

{Con't to 809-C}
Stephen RichardsonTELEPHONE: (916) 263-4700
Arvin VillanuevaTELEPHONE: 916-208-0023
DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 HOME VI
FACILITY NUMBER: 347005343
VISIT DATE: 07/14/2025
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{Con't from 809} Fire extinguishers were observed in the kitchen area and hallway and were last inspected on 3/5/2025. Smoke and carbon monoxide detectors combination were observed throughout. LPA observed centrally stored medications, toxins, and sharp objects were kept locked and inaccessible to residents in care.
In the kitchen area, LPA observed sufficient seven day non-perishable and two day perishable food supplies. Pantry was observed to be fully stocked with non-perishable food items. Proper storage of food items were observed. Kitchen refrigerator/freezer were observed to be clean.
Outdoor area was inspected. LPA observed outdoor furniture for resident use. Ramps were observed to be in good repair at this time. Emergency walkways were observed to be unobstructed. Fence and gates were in good repair at this time. LPA observed a covered porch going to the backyard.
Record Reviews:
Review of 4 of 4 resident files (R1, R2, R3, R4) was conducted, include review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status. Advisory was provided to update R1's Needs and Services Plan; it was last updated 3/24/22. A signed PRN Authorizations were needed for R3 and R4. Per S1, they are still trying to get their doctors to review and sign the form.
Medication review of 2 residents (R3, R4) include review of physician orders for over-the-counter medications. No issues were noted at this time.
Review of 3 staff files (S1, S2, S3) include review of background clearance, First Aid/CPR certificate, Health Screen, Initial and Ongoing Training. Per review and interview, S1 does not have a current Administrator Certificate. It was determined through record review that S1's Administrator certificate expired on 3/10/2025. Per interview, S1 submitted the application for renewal after the expiration of his Administrator Certificate. Per review of the he Community Care Licensing Division Administrator Certification Section confirmed that a S1's Administrator Certificate was received on 5/22/2025.
LPA also reviewed fire drill/disaster drill records; facility conducts monthly drill.
LPA was provided a copy of current Liability Insurance Certificate, LIC500 and LIC308 during this visit.
Interviews:
LPA interviewed 1 staff. Residents were not available for interview during this visit as they were taking a nap.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were cited. Exit interview was conducted with S1. A copy of the report and appeal rights were provided upon exit.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-208-0023
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 07/14/2025 04:14 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 07/14/2025 at 04:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PALM VALLEY CARE HOME VI
FACILITY NUMBER: 347005343

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(a)
Administrator - Qualifications and Duties:
(a) All facilities shall have a qualified and currently certified administrator...
This requirement was not as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the current administrator does not hold a current Administrator Certification. The Administrator did not renew their certificate within the 2 year period. This poses potential health, safety, and personal rights risks to residents in care.
POC Due Date: 07/21/2025
Plan of Correction
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The Licensee agrees to appoint a temporary Administrator of record to the facility until S1’s administrator certificate renewal has been approved. At this time, the renewal is pending and might need to take additional continuing education units for late renewal.
LPA Villanueva requested a letter from the licensee appointing the individual as the Administrator, an LIC 308, a copy of the current Administrator Certificate, an LIC 200, an LIC 500 and an LIC 501 to be submitted to the Department by close of business on 7/21/25..
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (916) 263-4700
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: 916-208-0023
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2025


LIC809 (FAS) - (06/04)
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