<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202301
Report Date: 10/28/2020
Date Signed: 10/29/2020 12:49:18 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:
10/28/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Brisa Romero, Michael Sneper, Garry SneperTIME COMPLETED:
02:05 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/28/2020, Licensing Program Analyst Ryker Heberle, Licensing Program Managers Sarah Yip and Romeo Manzano, Regional Manager Vivien Helbling, Acting Assistant Program Administrator Krystal Moore, and Program Clinical Consultants Helen Shi and Myra Cunanan (PCCs), conducted an unannounced case management tele-visit via FaceTime with Executive Director Brisa Romero and Administrators Michael Sneper and Garry Sneper (Admins)

During the inspection, a facility staff member was observed failing to tuck sleeves of gown under gloves. another staff member was observed failing to dispose of gloves and gown after they exited and re-entered resident rooms in isolation area. Staff member also failed to perform proper hand hygiene and replace their gloves when entering the rooms of 2 separate residents.

While in isolation area, department observed uncleared COVID positive resident being served lunch in the isolation wing with three other cleared residents and two negative staff members.

Dumpster used for the disposal of PPE was also observed uncovered.

After the inspection, the department requested Admins to provide a written agreement between the facility and the home health agency used in the care of two residents. Admins stated that they did not have a written agreement and that they believed that it was the responsibility of either resident's PCP or home health agency to provide said agreements.

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

DATE: 10/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2020
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 6
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: 10/28/2020
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
PCC Shi made the following recommendations and requests of the facility:
  1. For any positive residents under hospice, verify how often hospice staff will enter the facility and what their care plan entails
  2. Obtain doctor's order for resident's pressure wound skin care and deliver to PCC by COD 10/28/2020
  3. Within the facility line list, begin indicating percentage of food/drink consumed by residents with stifled appetite and update daily
  4. Follow up with symptomatic COVID positive staff members and ask them whether or not they have already had appointments with their primary care physicians regarding their symptoms and projected clearance dates. Indicate on updated line list
  5. Ensure residents under isolation order stay in their rooms and do not co-mingle with cleared residents
  6. Ensure that trash receptacles (including dumpsters) remained sealed with lids at all times
  7. Provide staff with additional training by Infection Protection Specialist on the proper donning and doffing of PPE
  8. Update facility LIC500 to indicate Veronica as IP specialist and add additional med tech covering Veronica's position by COD 10/28/2020
  9. Housekeeping and Deep Cleaning Schedules as well as caregiver cleaning duties shall be outlined and delivered to department by close of business day 10/28/2020
  10. Submit AYA Contract for IP nurse by close of business day 10/27/2020. Not completed as of 10/28/2020
  11. Submit RN network completion, was due on 10/27/2020. Not completed as of 10/28/2020.
  12. Based on serious citations today involving infection control and mitigation of COVID-19, licensee shall have a full time infection prevention specialist in the facility immediately or no later than 10/30/2020.
  13. Nurse Consultant Supervisor requested employee COVID test results for September of 2020 be delivered to department by 10/28/2020. Documents received 10/27/2020
Deficiencies were observed and cited under Title 22, Division 6, Chapter 8. This report and the appeal rights were discussed with Executive Director Brisa Romero
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2020
LIC809 (FAS) - (06/04)
Page: 6 of 6
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/29/2020
Section Cited

1
2
3
4
5
6
7
87468.1(a)(2) Personal Rights - To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
8
9
10
11
12
13
14
a resident positive with COVID-19 who is required to be in isolation was observed in a common area with 2 residents and 2 staff. The other 2 residents are now cleared and 2 staff are negative of COVID-19.
8
9
10
11
12
13
14
Type A
10/29/2020
Section Cited

1
2
3
4
5
6
7
87468.1(a)(2) Personal Rights - To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requireent was not met as evidenced by:
8
9
10
11
12
13
14
2 staff members were observed failing to don and doff PPE correctly. One staff did not tuck the sleeves of her gown into her gloves. One staff did not doff and do hand hygiene before leaving the Covid unit. The staff did not remove dirty gloves and did not do hand hygiene. When asked to return to the Covid unit, staff, still with the used PPE on went back and used the dirty glove to press the key pad to go back inside the Covid unit. Staff also did not do hand hygiene and change gloves when staff entered the rooms of 2 positive residents.
8
9
10
11
12
13
14
POC date
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2020
LIC809 (FAS) - (06/04)
Page: 4 of 6
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/29/2020
Section Cited

1
2
3
4
5
6
7
87303(f)(3) All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers. This requirement was not met as evidenced by:
8
9
10
11
12
13
14
a garbage dumpster used in the disposal of PPE was observed uncovered during tele-visit on 10/28/20.
8
9
10
11
12
13
14
Type A
10/29/2020
Section Cited

1
2
3
4
5
6
7
87211(a)(2): Occurrences, such as epidemic outbreaks, which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours. This requirement was not met as evidenced by:
8
9
10
11
12
13
14
Licensee did not report positive cases of COVID-19 in the facility to the department. No LIC 624s submitted to department alerting of potential COVID-19 positives.
8
9
10
11
12
13
14
Licensee is to submit this plan to CCL by POC date
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2020
LIC809 (FAS) - (06/04)
Page: 2 of 6
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/29/2020
Section Cited

1
2
3
4
5
6
7
87609(b)(4): The licensee and home health agency agree in writing on the responsibilities of the home health agency. This requirement was not met as evidenced by:
8
9
10
11
12
13
14
licensee did not have home health agreements maintained for 2 residents in the facility receiving home health care.
8
9
10
11
12
13
14
by POC date
Type A
10/29/2020
Section Cited

1
2
3
4
5
6
7
87405(d)(2): The administrator shall have the qualifications specified. Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by:
8
9
10
11
12
13
14
licensees did not conform to applicable laws and regulations including requirements in COVID-19 infection control and mitigation resulting in serious violations issued against the licensees on 10/29/2020
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2020
LIC809 (FAS) - (06/04)
Page: 3 of 6
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/29/2020
Section Cited

1
2
3
4
5
6
7
1568.082(3): Conduct which is inimical to the health, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California. This requirement was not met as evidenced by:
8
9
10
11
12
13
14
Licensees failed to comply and cooperate with technical assistance recommendations, did not submit mitigation plan timely after many reminders as provided by the Department to ensure licensee has infection control and mitigation of COVID-19 in place in the facility.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2020
LIC809 (FAS) - (06/04)
Page: 5 of 6