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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202301
Report Date: 10/27/2020
Date Signed: 10/27/2020 04:58:47 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:PALM VILLAS, CAMPBELLFACILITY NUMBER:
435202301
ADMINISTRATOR:SNEPER, GARRYFACILITY TYPE:
740
ADDRESS:3333 SOUTH BASCOM AVENUETELEPHONE:
(408) 559-8301
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:48CENSUS: 23DATE:
10/27/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Brisa Romero, Gary Sneper, Michael SneperTIME COMPLETED:
02:30 PM
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On 10/27/2020, Licensing Program Analyst Ryker Heberle, Licensing Program Managers Romeo Manzano and Sarah Yip, Regional Manager Vivien Helbling, Program Clinical Consultants Helen Shi and Myra Cunanan (PCCs), Acting Assistant Program Administrator Krystal Moore, and Assistant Program Administrator Stacy Barlow conducted a status check tele-conference visit with Executive Director Brisa Romero and Administrators Michael Sneper and Garry Sneper (Admins).

Admins stated that Doctor Steinke (Dr.) was on site and advised managerial staff and IP specialist Veronica on what facility needs to accomplish for infection protection. Admins sent Dr. updated COVID mitigation plan. Admins are awaiting his input and will submit the revised plan by COB 10/27/20. Dr. will return on Thursday from 10am to 2pm.

Department made the following recommendations:
1. Submit updated mitigation plan with Dr. Steinke's instructions by COB 10/27/2020

2. Department recommended that the facility update their line list to accurately reflect staff clearances with all columns being revised to remain consistent with one another.

3. Facility will send pictures of changed labels on cleaning supplies by COB 10/27/2020.

4. Cleaning schedule details will be delivered to PCCs by COB 10/27/2020

5. Admins will supply RN network with detailed description of required duties for on-site nursing staff.

Continued on 809-C
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020
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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: PALM VILLAS, CAMPBELL
FACILITY NUMBER: 435202301
VISIT DATE: 10/27/2020
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6. Admins will review and submit AYA contract for IP nurse.

No deficiencies cited during visit

Report was reviewed with Executive Director Brisa Romero and an electronic copy was provided for signature on 10/27/2020.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020
LIC809 (FAS) - (06/04)
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