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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366411347
Report Date: 12/16/2024
Date Signed: 12/16/2024 03:12:14 PM

Document Has Been Signed on 12/16/2024 03:12 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:PALM CARE HOMEFACILITY NUMBER:
366411347
ADMINISTRATOR/
DIRECTOR:		CUELLAR, CARMENFACILITY TYPE:
735
ADDRESS:732 SOUTH PALM AVENUETELEPHONE:
(909) 820-9859
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 6CENSUS: 0DATE:
12/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:08 PM
MET WITH:Carmen Cuellar, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analysts (LPA) La Vette Farlow arrived to conduct the required annual visit to the facility. LPA met with Administrator Carmen Cuellar, and introduced self and stated purpose of the visit. LPA was informed that the current census is three (3). Two (2) of the three (3) resident are away at the day program.

The facility has 3 resident bedrooms, 2 bathrooms, extra bedroom for staff, office area, kitchen, dining area, family room, living room, laundry area, attached garage, and backyard. The facility is vendorized by Inland Regional Center. LPA completed a walk through of facility, review of records, medication and P&I audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 75 degrees Fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected client bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 109.1 and 112.9 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms and charged fire extinguisher. Posters such as; the personal rights, CCL complaint poster and disaster plans were posted in the facility. Cleaning supplies, toxins, sharps, and other dangerous items were kept in secure cabinets inaccessible to clients. There was a designated storage space for client/staff files. Medications and first aid kit were observed in secure cabinets and inaccessible to clients. The facility had emergency kits in the hallway closet for clients in care. There are no firearms, ammunition, pool or bodies of water in the facility. Overall, the facility is clean, and operational.
Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a wide variety of food available for clients. Dishes, cups, and utensils were also stored properly. Emergency food and water were also observed.

Yards/Outside: LPA observed one shaded patio, side gates with self-latching handles on the left side and right side of the house.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2024
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PALM CARE HOME
FACILITY NUMBER: 366411347
VISIT DATE: 12/16/2024
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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.

Record Review: LPA reviewed 2 client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed Licensee and two (2) staff files for First Aid/CPR certification, criminal record clearances, training, and health screenings. P & I funds and medications were audited and appeared to be managed appropriately. The facility last conducted a disaster drill on December 2024.

No deficiency were cited during this visit. An exit interview was conducted where this report LIC809, and LIC809C, were discussed and copies were provided to Administrator Carmen Cuellar.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
LIC809 (FAS) - (06/04)
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