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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600787
Report Date: 10/31/2023
Date Signed: 10/31/2023 12:48:13 PM


Document Has Been Signed on 10/31/2023 12:48 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
SF COASTAL AC/SC, 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: 38DATE:
10/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Nora SaavedraTIME COMPLETED:
01:15 PM
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On this day, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required 1 year annual inspection. LPA met with resident services director Nora Saavedra who also holds a valid administrator certificate. The administrator Garry Sneper is not present on this day. LPA met with Nora and explained the purpose of today's visit.

LPA was allowed entry into the facility that is licensed to serve 49 residents all of whom may be non-ambulatory. Annual Fees are current. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed the facility kitchen which is locked from resident access. Knives are stored within the kitchen behind closed door. Perishable and non-perishable food items are observed as in place. LPA observed the the medication room is behind a counter and has a lockable door. Resident medications are in place and current. The first aid kit is maintained in the medication room and is complete with required items. LPA observed a pull alarm fire system, fire extinguishers through out the facility inspected 02/23/23, smoke detector/carbon monoxide detectors, fire sprinklers through out, and central heating in the facility as in place. PPE and additional food supplies are observed on the second floor of the facility. Laundry room is also observed on the second floor as fully operational. Emergency exit routes are observed inside and outside to be free and clear of obstructions.

LPA reviewed resident files and staff files which are all current. The facility does not handle resident money. Liability insurance is observed as in place and current. Current administrator certificate shows as pending renewal as of 06/05/2023.

Upon a file review the following items are requested to be submitted by 11/07/2023:

- Infection Control Plan (LIC9282)
- Designation of Facility Responsibility (LIC308)
- Personnel Report (LIC500) to include the Administrator presence in the facility
- Updated administrator Certificate
- Emergency Disaster Plan (LIC610E)
- Copy of certificate of liability insurance

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies observed or cited. Report reviewed with Nora Saavedra.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023
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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