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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366411347
Report Date: 12/26/2023
Date Signed: 12/26/2023 12:37:42 PM

Document Has Been Signed on 12/26/2023 12:37 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: 0DATE:
12/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Carmen Cuellar, AdministratorTIME COMPLETED:
12:45 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Palm Care Home, Adult Residential Facility to conduct an Annual Inspection. LPA was greeted by Administrator Carmen Cuellar, who granted LPA entry. LPA introduced self and stated purpose of the visit. LPA informed that the four, (4) residents in care are on an outing at the time of the visit.

The facility is an Adult Residential Facility (ARF) licensed and approved for 6 ambulatory residents. The facility maintains a partnership with the Inland Regional Center, (IRC). LPA was accompanied by Facility Administrator to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. LPA inspected client bedrooms. Each resident room was equipped with all required furniture such as: mattresses with appropriate linens, night stands, adequate storage space, and lighting. LPA inspected the resident bathroom and found it was orderly with operational appliances. The bathroom was equipped with adequate hand hygiene and paper supplies for residents in care. LPA observed sufficient furniture for seating and lighting throughout the facility. The hot water temperature tested and found within regulatory limits. The facility is equipped with operational smoke/fire detectors and carbon monoxide alarms. Fire extinguishers located in the facility were last inspected November 2023. Posters such as personal rights, the Community Care Licensing Complaint poster, and the disaster plan were posted in a prominent area and kept in a binder. Cleaning supplies, toxins, sharps, and other dangerous items were kept in the kitchen secure and inaccessible to residents in care. There was a designated storage space for client/staff files; also secure. Medications are kept secure in the kitchen inside medication closet secure and also inaccessible to residents in care.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 12/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/26/2023
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 CARE HOME
FACILITY NUMBER: 366411347
VISIT DATE: 12/26/2023
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Food Service: LPA observed two cabinets fully stocked with non-perishable goods all in good standing. Perishable food supply in the refrigerator and freezer was sufficient for number of residents in care. Facility has a variety of food available for residents. Dishes, cups, and utensils were adequate in amounts and also stored properly.

Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care. Based on observations, no deficiencies will be cited per Title 22, California Code of Regulations. A copy of this report was read/reviewed with Licensee; signature acknowledges understanding and receipt of report and attachments.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023
LIC809 (FAS) - (06/04)
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