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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366411347
Report Date: 12/19/2022
Date Signed: 12/19/2022 02:39:05 PM

Document Has Been Signed on 12/19/2022 02:39 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:PALM CARE HOMEFACILITY NUMBER:
366411347
ADMINISTRATOR:CUELLAR, CARMENFACILITY TYPE:
735
ADDRESS:732 SOUTH PALM AVENUETELEPHONE:
(909) 820-9859
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 6CENSUS: 4DATE:
12/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Carmen Cuellar, AdministratorTIME COMPLETED:
02:50 PM
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Licensing Program Analyst, Amber Coleman (LPA) arrived at the Palm Care Home to conduct the annual inspection with a focus on infection control. LPA introduced self and stated purpose of the visit. LPA was greeted and granted entry by Administrator Carmen Cuellar. staff member, Olmedo Mendoza was present during walk through. Administrator informed LPA that the residents were currently in Day Program. The current census is 4. At this time, there are no residents experiencing symptoms or are suspected to have COVID. With the exception of one, all staff and residents have been vaccinated. LPA observed the facility to be orderly and free of obstructions.

LPA and Administrator completed a walk through the facility inside and outside. LPA observed the facility's COVID station in a room adjacent to the kitchen. The COVID station contained hand sanitizer, questionnaires and PPE. Above the station were posted infection control signs. Each bathroom was adequately equipped with hand soap, paper towels and wastebaskets.

The facility staff recited their a plan to manage Covid-19 symptoms, this includes staff monitoring residents regularly for any changes in condition, keeping residents 6ft apart, staggering meal times daily temperature checks and cueing residents to wash their hands, The facility staff will contact the resident's physician and family in the event of any COVID-19 related illnesses. The facility staff are responsible for cleaning and disinfecting the highly touched surfaces during their shifts.

Resident's rooms had the required furniture and sufficient lighting. The restrooms were observed to be fully stocked with hand soap and paper products. The facility had a supply of additional linen and extra hygiene items for the residents.

In the kitchen LPA observed an appropriate amount of food to accommodate residents in care. Sharp objects were kept secure in a file cabinet in the kitchen; along with the resident's medications. Chemical were observed secure under the kitchen sink. The emergency food supply is kept in a secure file cabinet near the kitchen. Fire and carbon monoxide alarms were tested and found to be operational. Fire extinguishers last inspected 12/12/22. The backyard was observed to contain adequate seating in a shaded area.

Inspection Tool was utilized, Mitigation plan was reviewed. Facility was further inspected, and no deficiencies were noted.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2022
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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