361881047-5-11-2023-56-AS-MMAE-CRQTAD-20230511143323

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361881047
Report Date: 05/11/2023
Date Signed: 05/11/2023 02:34:02 PM

Document Has Been Signed on 05/11/2023 02:34 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	GOLDEN PALM LIFE CARE		FACILITY NUMBER:	361881047
ADMINISTRATOR:	SANTIAGO, JAMES		FACILITY TYPE:	735
ADDRESS:	2831 PALM AVE		TELEPHONE:	(909) 223-8481
CITY:	HIGHLAND	STATE: CA	ZIP CODE:	92346
CAPACITY: 4		CENSUS: 2	DATE:	05/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:55 AM
MET WITH:	Dominador Bartolata, Direct Staff Provider		TIME COMPLETED:	02:35 PM

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On 5/11/23, Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced, required annual inspection to the facility. LPA met with Dominador Bartolata, Direct Staff Provider (DSP) and discussed the purpose of the visit. The facility is an Adult Residential Facility licensed for four (4) ambulatory clients. At the time of the visit, two (2) clients and two (2) staff were present at the facility . LPA conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: LPA observed no obstructions to indoor and outdoor passageways. Outside gates are self-latching. LPA observed a hot tub which is kept covered, locked and inaccessible to clients in care. Facility is clean and free from odors. The facility is maintained at a comfortable temperature of 69 degrees F. Facility equipped with sufficient lighting. Client bedrooms are equipped with mattresses, nightstands, storage space, sufficient lighting. Bathrooms were clean, equipped with hand rails, appliances were operating appropriately. LPA observed furniture is in good repair and sufficient for clients in care. The hot water temperature tested within regulation at 112 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked and inaccessible to clients in care. There was a designated storage space for client/staff/facility files. Medications are locked and inaccessible to clients in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a monthly menu with a variety of food available for clients.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GOLDEN PALM LIFE CARE	FACILITY NUMBER: 361881047
	VISIT DATE: 05/11/2023

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Record Review: LPA reviewed two (2) client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. All medications for clients in care were viewed and dispensed appropriately as prescribed.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22 of the California Code of Regulations.

An exit interview was conducted was where this report was discussed and a copy with appeal rights was provided to Direct Staff Provider at the conclusion of the visit..

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023

LIC809 (FAS) - (06/04)

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