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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881047
Report Date: 04/21/2022
Date Signed: 04/21/2022 04:19:00 PM

Document Has Been Signed on 04/21/2022 04:19 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:GOLDEN PALM LIFE CAREFACILITY NUMBER:
361881047
ADMINISTRATOR:SANTIAGO, JAMESFACILITY TYPE:
735
ADDRESS:2831 PALM AVETELEPHONE:
(909) 223-8481
CITY:HIGHLANDSTATE: CAZIP CODE:
92346
CAPACITY: 4CENSUS: 0DATE:
04/21/2022
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
01:16 PM
MET WITH:James Santiago, Dominador Bartolata and Evelyn MercadoTIME COMPLETED:
02:55 PM
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Licensing Program Analysts (LPAs) Rayshaun Nickolas and Anna Bueno made an announced visit to the facility to conduct an annual inspection with an emphasis on infection control. LPAs arrived at 1:16 PM and were met by James Santiago (administrator). There are currently no clients in care as the facility is awaiting vendorization from Regional Center. There are no cases of COVID-19 within the facility.

During today's visit, LPAs toured the facility and made observations pertaining to the facility's infection control measures. Although there were no Personal Protection Equipment (PPE) on site, the administrator states that they do have PPE at another facility. LPAs observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and proper use of face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE and overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and clients for COVID-19, when and how to isolate/quarantine clients, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor clients regularly for any changes in condition and to subsequently notify the resident's physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

Based on the observations made during today’s visit, there were no deficiencies cited per Title 22, Division 6, of the California Code or Regulations. An exit interview to review this report was conducted and a copy of this report was provided to staff.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2022
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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