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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005343
Report Date: 07/13/2023
Date Signed: 07/13/2023 02:43:54 PM


Document Has Been Signed on 07/13/2023 02:43 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:PALM VALLEY CARE HOME VIFACILITY NUMBER:
347005343
ADMINISTRATOR:GERWIN SICATFACILITY TYPE:
740
ADDRESS:8644 BANFF VISTA DRIVETELEPHONE:
(916) 612-7209
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 4DATE:
07/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Gerwin SicatTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct an annual required visit. LPA met with Administrator Gerwin and explained the purpose of the visit.

LPA and Administrator toured the facility inside and out to ensure compliance with Title 22 regulations. LPA observed bedrooms, bathrooms, common areas, kitchen area, dinning area, and exterior areas. Three out of 4 residents were observed to be taking a nap during the visit. 1 out 4 residents were reading a book.
Fire extinguishers with last check on March 2023 was observed to be in working condition. The facility temperature was comfortable at 74*degrees. The facility was observed to have an adequate supply of food to meet the requirements of 2 days of perishable foods and 7 days of non-perishables foods. An emergency supply of food was also observed. The exterior area has a large outdoor sitting area for residents and/or visitors.

LPA Valerio requested the following documentation: LIC 500, LIC 308, LIC 610D, Liability Insurance

Per California Code of Regulations (CCR), Title 22, no deficiencies were observed during today's visit. An exit interview was held, and a copy of the report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2023
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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