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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600787
Report Date: 05/06/2022
Date Signed: 05/06/2022 11:41:55 AM


Document Has Been Signed on 05/06/2022 11:41 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:PALM VILLASFACILITY NUMBER:
415600787
ADMINISTRATOR:SNEPER, GARRYFACILITY TYPE:
740
ADDRESS:1931 WOODSIDE ROADTELEPHONE:
(650) 369-3197
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY:49CENSUS: 41DATE:
05/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Garry SneperTIME COMPLETED:
12:00 PM
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On this day at 1400 hours, Licensing Program Analysts (LPA) Jaime Vado conducted an unannounced infection control annual required inspection. LPA met with administrator Garry Sneper and explained purpose of today's inspection.

LPA toured facility's building and grounds. Upon entry LPA was screened for COVID with temperature taken and COVID related questions asked. COVID signs are posted on door prior to entering main facility. Additional social distancing signs and masking signs to be posted in main hallways. There are no accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring and staff monitoring, containment strategies, environmental preparation and cleaning are in place. PPE supply is observed as in place. Medications, toxins and sharps are stored appropriately and inaccessible to residents in medication room. Medication cart observed as locked with narcotic medications. Facility ambient temperature is comfortable and lighting is sufficient for residents and staff safety. Toilet and bathing facilities are equipped with grab bars and non-slip mats. Liquid soap is available in resident bathrooms and paper towels for resident use. Hand washing signs in bathrooms are advised to be posted. First-aid kit is inspected as complete. A Disaster and Mass Casualty Plan observed dates 4/2/2022. All staff observed are wearing masks. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed as current. Administrator certificates are current. All residents and staff are fully vaccinated and with booster. Mitigation plan is present and is reviewed. Additional COVID materials are reviewed in Disaster Manual binder. According to him the mitigation plan is current and is still in use. Staff first aid cards are current and in place as well as training.

The following updated forms are requested to be submitted to CCLD by 05/13/2022:

• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• LIC 610E Emergency Disaster Plan
• LIC 9020 Resident Roster
• Updated copy of administrator certificate

No deficiencies cited. Report is reviewed with Garry.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2022
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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