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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530208
Report Date: 05/08/2024
Date Signed: 05/08/2024 11:36:56 AM

Document Has Been Signed on 05/08/2024 11:36 AM - 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:PALM HOUSEFACILITY NUMBER:
365530208
ADMINISTRATOR/
DIRECTOR:		SAMSON, JESILINE CFACILITY TYPE:
735
ADDRESS:16234 PALM STTELEPHONE:
(626) 318-1864
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 4CENSUS: 0DATE:
05/08/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Jesiline Samson, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Magda Malcore conducted an announced visit to complete the Pre-licensing inspection. LPA met with Jesiline Samson, Administrator, and discussed the purpose of the visit. An initial application to operate an Adult Residential Facility (ARF) was submitted to the Central Applications Unit (CAU). A fire clearance was granted by the San Bernardino Fire Department on 4/02/24 for a total capacity of (4) and includes clearance for two (2) non-ambulatory clients. LPA observed the following:

Physical Plant: Indoor and outdoor passageways are free of obstruction. The facility has no swimming pools or similar bodies of water. The facility window screens were observed to be in good repair. The facility has sufficient shaded outdoor space and sufficient indoor space for client activities. The facility has sufficient lighting and is maintained at a comfortable temperature. The facility has operating telephone service, smoke/carbon monoxide alarms, and laundry equipment. The facility has posted in a common area, emergency exiting plan and telephone numbers, personal rights, Licensing complaint information, and facility visiting policy. Sharps and cleaning supplies are kept in a locked cabinet.

Bedrooms/Bathrooms: Client bedrooms are equipped with mattresses, bed linen, chairs, nightstands, and sufficient lighting. Client bathrooms are clean and equipped with operating toilets, washbasins, showers, and covered waste bins. The hot water temperature measured 108 degrees F. Night lights were observed in the hallway area outside of client bathrooms.

Food Service: The kitchen and dining areas are maintained clean. The facility has an adequate number of cups, dishes, and utensils. The facility has a sufficient seven (7) day supply of non-perishable foods . The refrigerator and freezer have sufficient space for at least two (2) days of perishable foods.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2024
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 2
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: PALM HOUSE
FACILITY NUMBER: 365530208
VISIT DATE: 05/08/2024
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Medications: The facility has a designated locked cabinet for client medications.

Supplies: The facility has sufficient supply of clean bed linen, bath towels, paper towels, personal hygiene products, client activity items, emergency flashlights and first-aid.

Records: The facility has a designated storage area for client and staff files.

Overall, the facility is clean and in good repair. The Prelicensing inspection and the Comp III orientation are complete; no corrections are required.



An exit interview was conducted where this report was discussed and a copy of this report was provided to the Administrator at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024
LIC809 (FAS) - (06/04)
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